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Surgeon General Nominee Murthy Loses Support Of Key Backers

CommonHealth (WBUR) - Wed, 10/22/2014 - 5:09pm

Dr. Vivek Murthy (Charles Dharapak/AP/File)

One of the country’s leading medical journals is withdrawing support for a Brigham and Women’s Hospital physician nominated by President Obama to become the next surgeon general.

The New England Journal of Medicine (NEJM) endorsed Vivek Murthy in May, but an editorial published Wednesday withdraws that support.

Although we believe that Vivek Murthy would bring much to the job, the harsh political environment in Washington is unlikely to allow his confirmation. Given this impasse, and in these critical times, the Obama Administration should select another candidate to be the nation’s public health leader.

Murthy’s nomination has languished for months, a target of the National Rifle Association which objects to Murthy’s view that gun violence is a public health issue.

The NEJM editorial says the country needs a surgeon general now who can speak to the public with authority about Ebola, the coming flu season and various viral outbreaks such as Enterovirus D68.

There is no response yet from Murthy or the White House.

Dr. Greg Curfman, NEJM’s executive editor, joined WBUR’s All Things Considered to explain the abrupt change. Listen to his full conversation with WBUR’s Deborah Becker above. 

Categories: Health Care

E-Cigarette Debate: 7,000 Flavors Of Addiction, But What Health Risks?

CommonHealth (WBUR) - Wed, 10/22/2014 - 2:06pm
[Watch on YouTube]

I’m not young or edgy enough to hang out with anyone who smokes e-cigarettes, but I’ve been vaguely aware that they’re a big and growing thing, and the focus of a big and growing controversy. To wit: Do they end up a net positive, because they help people quit the classic “cancer sticks,” or a net negative, because they act as “gateway” cigarettes just when we’ve finally beaten our smoking rates down?

Answer: We don’t know yet. That’s my takeaway from a major multi-media project on electronic cigarettes on Boston University’s new research Website. But it’s such an important question that it’s even a source of debate between prominent researchers on campus — though both strongly concur that more research is needed. From “Behind The Vapor:”

At Boston University, Avrum Spira, a pulmonary care physician and School of Medicine associate professor of pathology and laboratory medicine and bioinformatics who studies genomics and lung cancer, was one of the first scientists to receive funding from the FDA to investigate the health effects of e-cigarettes. “In theor y—- and how they’re marketed — e-cigarettes are a safer product because they don’t have tobacco, which has known carcinogens,” Spira says. “The question is: does safer mean safe?”

(From the Boston University video)

Across BU’s Medical Campus from Spira, Michael Siegel, a physician and professor of community health sciences at the School of Public Health, has emerged as perhaps the country’s most high-profile public health advocate for e-cigarettes. Siegel, who is not currently researching e-cigarettes, says he believes that the device could potentially help large numbers of smokers quit, or drastically decrease, a habit that is the leading cause of preventable deaths in the US. He points out that despite all the existing smoking cessation products on the market, only a small fraction of cigarette smokers manage to quit. Only 4 to 7 percent break the habit without some nicotine replacement or medication, according to the American Cancer Society. At the same time, Siegel says, more research is needed on the health effects of e-cigarettes as well as their effectiveness in helping people quit smoking.

Check out the full project here, including the video above, “7,000 Flavors of Addiction.” And while you’re on the new Website, a couple of other particularly grabby features: The Secret’s In The Spit (the gluten-saliva link — who knew?) and The Secret Life of Neutrinos.

Categories: Health Care

Hospitals Struggle To Beat Back Serious Infections

Kaiser Health News - Wed, 10/22/2014 - 1:16pm

KHN reporter Jordan Rau spoke on NPR about data that say about 75,000 patients per year die from infections they got in the hospital. Nearly 700 hospitals around the U.S. have higher than expected infection rates.

Listen below to the interview:

Categories: Health Care

Reality Check: How People Catch Ebola, And How They Don’t

CommonHealth (WBUR) - Wed, 10/22/2014 - 10:15am

Dr. Elke Muhlberger (Courtesy of Kalman Zabarsky for BU Photography)

It’s confusing. You hear that Ebola victim Thomas Eric Duncan was so contagious that two Dallas nurses in protective gear caught the virus. But then you hear, in more recent days, that apparently nobody else did, including the inner circle who lived with him and cared for him. The CDC announced today that all of Mr. Duncan’s “community contacts” have completed their 21-day monitoring period without developing Ebola.

How to understand that? And how to address alarmists’ claims that for the nurses and so many West Africans to have caught Ebola, it must have gone “airborne”?

I turned to Dr. Elke Muhlberger, an Ebola expert long intimate with the virus — through more than 20 years of Ebola research that included two pregnancies. (I must say I find this the ultimate antidote for the fear generated by the nurses’ infections: A researcher so confident in the power of taking the right precautions that she had no fear — and rightly so, it turned out — for her babies-to-be.)

Dr. Muhlberger is an associate professor of micriobiology at Boston University and director of the Biomolecule Production Core at the National Emerging Infectious Diseases Laboratories (widely referred to as the NEIDL, pronounced “needle”) at Boston University. Our conversation, lightly edited:

Is it really true you worked on Ebola through two pregnancies?

More Ebola Coverage From CommonHealth:

Yes, but in the proper protective gear. That makes a huge difference, if you’re protected, if you know how to protect yourself, and that is the case in a Biosafety Level 4 lab, of course. If you compare the protective gear we’re wearing in a Biosafety Level 4 lab and the gear they’re wearing in West Africa now treating patients, it’s like comparing a stainless steel vault to a cardboard box.

But on the other hand, if you look at the nurses in Dallas, you say, ‘How did they get infected?’ It makes you worry that maybe protective gear isn’t good enough — but you’re proof of the opposite.

A Biosafety Level 4 lab is such a high-end lab, it is not possible to use protective gear like that in every hospital in the U.S.

Could you please lay out a brief primer on the biology of how Ebola is transmitted?

We know from previous outbreaks, and also from the current outbreak, that Ebola is transmitted by having very close contact to infected patients. So we know that it is transmitted by bodily fluids, which include blood, first of all — because the amount of virus in the blood is very, very high, especially at late stages of infection — but it’s also spread by vomit, by sputum, by feces, by urine and by other bodily fluids.

The reason for that is that at late stages of infection, the Ebola virus affects almost all our organs — it causes a systemic infection. One main organ targeted by Ebola virus is the liver, and that could be one of the reasons that we see these very high concentrations of viral particles in the blood. But I would like to emphasize that that occurs late in infection.

Early infection is the other way around. The primary targets — the first cells that come in contact with Ebola virus and get infected — are cells that are part of our immune system. And these cells most likely spread the virus throughout our body. But there are not so many cells infected at the very beginning of the infection, which might be the reason why Ebola virus patients do not spread virus at the very beginning of infection. And that’s why it’s safe to have contact with these patients, because the viral titers in their blood are so low that we cannot even detect them with methods like PCR, which is one of the methods we use to diagnose Ebola virus.

Is a virus only contagious when it reaches a certain level of “titer” or load?

That’s very difficult to answer because we know that for some viral infections most likely one viral particle is enough to infect somebody. So then the answer would be no. But we also know that some viruses are not really good spreaders, so you do need a certain amount of viruses to transmit this virus to another person.

Is that true for Ebola?

For Ebola virus, it seems to be true, because from experience, we know that this virus is not transmitted early in infection. If the viral titers are very low, if you’re not able to detect free viruses in the blood, then it seems Ebola virus is not transmitted to other people. Which is very good because, theoretically, that makes it really easy to control Ebola virus infection. And the reason why we have such a disaster right now, with almost 10,000 infected in West Africa and more than 4,000 already dead, is not so much the transmissibility of Ebola but rather the lack of infrastructure in these countries.

Some people are claiming that to infect so many people, the virus must have moved from just bodily fluids to “airborne”…

I think there’s some confusion here. We know that some viruses — like influenza virus, and measles — are transmitted before the patient shows symptoms. Especially the measles virus, which is the winner in terms of being contagious. What these viruses do is infect the respiratory tract — that is their first target organ. That’s how they start the infection, and then they replicate or amplify themselves in cells of the upper respiratory tract. And then when we breathe, we release these viruses because they’re part of our ‘breathing air.’ There are tiny, tiny, tiny little droplets, and these droplets contain the virus. They can stretch pretty far, like a couple of feet. And that is what we call an airborne infection. If we breathe and then we shed virus with our breath.

So you don’t even need visible droplets, it’s just air?

They’re tiny little droplets in our breath. And these viral particles are part of it. This is completely different from Ebola virus. First of all, Ebola virus does not begin an infection by infecting our upper respiratory tract. The route of infection starts with little lesions in our skin, and then the virus gets in our skin, and then in our blood system, and then in these immune cells I mentioned before, which are the primary target cells. It’s also able to get into our eyes and mucosal membranes, but it does not infect the cells which we need to get infected to have an infection be airborne. Late in the infection, when the Ebola virus patients have very high viral loads, they are really really ill, way too ill to get on a train and sit there.

So you’re saying that when they’re so ill that it could be in the respiratory system, they’re super-ill, not able to go anywhere?

Exactly. The cells in the lung can be infected by Ebola virus but really late in the infection. That’s very important. As far as we know, the infection starts with the immune cells — for those who know a little more about the immune system, it’s dendritic cells and macrophages. Then it goes to lymph nodes. Then very quickly to the liver, and there it goes crazy. The liver is very crucial in Ebola virus infections because it is so heavily affected. Ebola virus also spreads to the spleen, to other organs, and then later in infection it tends to infect the cells that coat the blood vessels, and of course we have these cells in the lung as well.

So when we are infected with Ebola virus and we are really sick, then we spread the virus through all our body fluids, which includes blood, sputum, feces urine, breast milk, urine and semen. Again, then we have Ebola virus in little droplets, which is the reason we talk about infection via droplets, but these droplets are much bigger — though they are tiny, of course — but these are much bigger than the droplets which cause aerosol-borne disease. So it’s a matter of size. And if they are bigger they cannot be transmitted over a large distance.

So if they’re bigger they can’t just float in your breath? But you could perhaps project them?

Of course you have them in your sputum — as you speak, you kind of shed virus — but then the droplets drop to the ground pretty quickly because they are heavier. It’s really a matter of size and weight.

The CDC recently tweeted an answer to a common Ebola question: It said yes, if someone with Ebola sneezes on you and the droplets land in your eyes or mouth, then conceivably you could catch Ebola. But that doesn’t count as airborne?

Exactly, and it’s all about timing. When someone is infected with measles and then sneezes or coughs, and is not sick at this point, they can transmit the virus to others and you’re not even aware that someone with the disease is contacting you. That’s the big difference with Ebola virus and these bigger droplets — but nevertheless droplets, of course. When Ebola virus patients start to transmit the virus, they have already developed a fever and are obviously sick.

So that helps explains why more people haven’t been infected in the U.S.?

Exactly. It’s very unfortunate, what happened in Dallas — that’s already the worst-case scenario for the U.S. It already happened to us. First, the patient came into the country without being identified as infected. That could happen again, just because of travel activity. Also, if the outbreak in West Africa is not controlled, more and more people will become infected. This makes it likely that infected patients will get into other countries. So that was the first thing that happened, which most likely is not easy to avoid.

Second — and this is something that could have been avoided — is that the infected person was not quarantined immediately, though we knew he had already gotten sick. He had contact with other persons who were not protected during his illness.

Finally, the nurses, who contracted the virus from the patient and eventually became ill, were not immediately quarantined and could have infected more people. And that is the worst-case scenario we can think of with Ebola virus.

Although what’s interesting is that, at least so far, aside from the two nurses, none of the people around Thomas Eric Duncan or the nurses has caught it.

Exactly. And that’s exactly what we know about Ebola virus: You really need close contact, especially contact with those who are severely ill, and that is because of of this special mode of transmission. Even early in infection it is not so contagious. Those who are at risk to get infected are those who take care of the ill patients — health care workers or relatives at home — and then the second group who got really hard hit by Ebola virus infections is those who care for the deceased, like relatives who washed the deceased, which is not really our funeral rites. So that is not a real risk for us, especially if you know someone died of Ebola virus.

Speculating, what do you think happened with the two nurses?

It’s a very interesting question. Since we know how to avoid Ebola virus infection, my assumption — but it’s really just an assumption — is that they did not wear the correct protective gear or, most likely, they were not trained to wear the protective gear correctly. Because you have to make sure that you protect every little bit of your skin, that’s so important. We talked about these droplets — if tiny little parts of your skin are not covered, and the patient is bleeding, and you get these droplets somewhere on your skin and then you have a tiny, tiny little scratch —

That maybe you can’t even see —

Exactly. And we all have little scratches, or your eyes are not properly protected. Even a little bit of unprotected skin — because of these little lesions we have in our skin — is enough to get infected. And it’s also important to think about how you take off your protective gear, because if you’re covered in the bodily fluids of the patient and then you have to take it off, how do you do that without touching your skin at one point?

So we are in a very fortunate position in the Biosafety Level 4 labs because we have chemical showers — and this is exactly why we have the chemical showers, to make sure that every part of us is somehow wetted with disinfectant, that we have contact with disinfectant everywhere. In the field, it’s very difficult to do that because you obviously don’t have chemical showers. Taking off the protective gear is something that needs a lot of training and very importantly, it needs a buddy system, you need somebody to help you to take off your protective gear. I don’t know if that happened in Dallas but that’s something that’s very, very important. That is really the most dangerous part of it: even if you wear this protective gear, at one point you have to take it off, and how do you do that without touching somewhere on your skin?

In some ways, Ebola transmission seems reminiscent of HIV. Could you please compare the two?

Comparing Ebola to HIV is like comparing a a bulldozer to a high-end intelligent robot. Because Ebola is not at all adapted to us, so it just infects us, it kills us pretty quickly or at least causes severe disease, and then when we are done, the virus is done as well because if the host is dead, the virus is dead as well. Ebola virus causes what we call an acute infection: It lasts about two weeks and then it’s over one way or the other.

HIV is completely different. HIV manages to get its little tiny genome into our genome in the cells, and some of these cells survive forever, and that’s the big issue with HIV. It becomes part of our own genomic equipment and so if these cells, which carry these little fragments, little HIV genomes, if they get activated, it really is not important how, then HIV starts to replicate its own genome and the infection starts again. That’s what we call a persistent infection, which is much, much harder to fight. With the Ebola virus, my guess is it’s much simpler to fight the infection.

And in terms of transmission?

I already mentioned that Ebola virus causes a systemic infection, so the entire body is affected by the infection. HIV is much more picky about the cells it would like to infect; it only infects a special subset of our immune cells — T cells — and it stays in these cells forever; until the cells die, it’s there. And since it is only in this special subset of blood cells, it’s only transmitted by blood and fluids, but not by sputum, for example, not by feces, not by saliva. The highest risk with HIV is sexual intercourse — it’s almost the only risk, and contact with blood, of course. And that makes it so different.

But nevertheless, because HIV lasts in our body forever once we are infected, that’s the reason why if you are infected with HIV and you don’t get treatment that helps you get the viral concentration down, then you theoretically can spread the virus as long as you live. And that is different from Ebola virus because Ebola is cleared after two weeks. You’re virus free and maybe even protected from a new Ebola virus infection. There’s a lot of speculation about that — we don’t know for sure if Ebola patients are protected going forward.

The news lately has been that in Dallas, people are coming off of quarantine after 21 days — that’s solid, that after 21 days you’re clear?

We know for Ebola virus the longest incubation period — the time from when you get infected to the time you show symptoms, that’s the incubation period — we ever heard about is 21 days. So if you’re healthy for 21 days, you do not have the infection.

And that’s different from having the infection and clearing it?

Then you have to do tests with these patients — you have to look at their blood and see if there’s still virus. Once you see there’s no virus in the blood — and you should repeat that at least two or three times to make sure there’s really no virus anymore — if this is the case then the patients are cleared and safe. With one exception — semen. That is a little bit strange, but it is as it is — it seems that Ebola virus can last in the body a little bit longer, because there are reports that it has been transmitted by sexual intercourse after seven weeks or so. But patients, if they know about that, they can easily take care of it.

Do we have any idea why that would be, biologically?

Sorry, no! it’s very weird, it was completely unexpected but it happened, unfortunately.

Was it a single case report? Or more?

I know about one report of a very similar virus — Marburg virus — so that was a very well-controlled outbreak in 1967 in Germany, in Marburg, and exactly that happened. And one of the patients who survived the infection then infected his wife, and that’s why we know about that. There have also been reports of detection of Ebola virus in semen almost three months after the infection.

As you’ve watched media coverage and public reaction, any other scientific corrections you’ve especially wanted to make, or additions to public understanding of how Ebola is transmitted?

I think we really should focus on the outbreak in Africa. To make it crystal clear, we do not have an Ebola virus outbreak in the U.S. We do have an Ebola virus outbreak in West Africa. We have to do all we can do to stop this outbreak for our own good because we do not want to have a similar situation as the Dallas patient.

I also want to make clear that this virus is not transmitted by the air, and this virus will not be transmitted by the air. In virology, we are not aware of a single virus which changed its transmission route so dramatically. I’ve asked a lot of my colleagues: Are you aware of any virus which changed its transmission route? Any virus which went from blood-borne or transmitted by bodily fluids to airborne? And nobody knew of any virus.

Ever?

Ever. In 100 years of virology. I would be glad to learn if that happened but I talked to a number of people and nobody could tell me a single example of that. It’s nature, you never know, a scientist never says never, but it’s very, very, very, very, very unlikely.

And I also want to mention, because we have cases not only here in the U.S. but I also heard about incidents in Europe — that there was somebody sitting on the train, throwing up, and people surrounded this person — a black person, which gives it some racist element too — and completely freaked out and called 911, ‘It’s Ebola, it’s Ebola!’ And that won’t happen because Ebola virus patients are really sick, and that’s also something you should keep in mind. They do not walk around happily and all of a sudden they start to throw up, that is not the case. It’s a deadly disease, and deadly means deadly, so you are ill and you won’t be able to walk around and infect people so easily.

You can’t really get out of bed by the time your fluids would be contagious?

Exactly.

Are there people who have been basically immune to Ebola virus?

That’s a very interesting question. There’s a very nice study by a French and African group, published in 2000, in which they identified what they called asymptomatic Ebola virus patients. There were people who had very close contact to Ebola virus patients but they did not become ill. They looked more closely at these people and they found that they had a very effective and well-regulated immune response to Ebola virus infection. They developed antibodies and they did not show any signs of infection. Obviously they were infected because they developed antibodies, but they were able to clear the infection.

So there are people like that…

Yes, but we don’t know why that is the case. One possibility could be that there are genetic differences, of course. Another possibility could be that they were infected with only very very tiny little amounts of virus and the immune system was able to clear the infection before the concentration goes up like crazy. But we don’t know the mechanism, not at all. That’s something that’s very important to learn: Why do some people get infected but not develop the disease?

Most media coverage says clearly that Ebola is not airborne, but there was one piece in the Los Angeles Times with the headline, “Some Ebola experts worry virus may spread more easily than assumed.” It referred to a monkey study in which monkeys that caught Ebola from each other were in close quarters and raised the question of whether it might be airborne.

If it’s the paper I think it is, there were no controlled conditions. It’s not really clear how the virus was transmitted. That’s scary. But we don’t know how that happened.

There is another study that was published more recently, with Ebola virus Zaire, by Gary Kobinger in Winnipeg: His team infected pigs with Ebola virus Zaire and then monkeys in the same room as the pigs got infected. They obviously transmitted the virus but pigs are not the most clean and neat animals and they were in the same room.

What is really important is then they did exactly the same study with monkeys only: They infected monkeys with Ebola virus and they had another set of monkeys in the same room in another cage. In this case, the monkeys were not infected with the Ebola virus. So it was pig to monkey but not monkey to monkey, with Ebola virus Zaire.

I feel so much better…

You should get your flu vaccine, that’s much more important. That’s my last message to everybody: Please get your flu vaccine.

Readers, lingering questions?

Further reading:
BU Today: Battling Ebola: Working With A Deadly Virus
The New Yorker: The Ebola Wars

Categories: Health Care

State Highlights: Health Care Takes Center Stage In Debates In Maine, Arizona, Missouri

Kaiser Health News - Wed, 10/22/2014 - 9:22am

A selection of health policy stories from Maine, Arizona, Missouri, Oregon, California, Florida, Pennsylvania, New Jersey, Kentucky and Connecticut.

The Associated Press: Sparks Fly Throughout Last Maine Governor Debate
The three candidates for governor clashed Tuesday in their final debate, highlighting their differences on a wide range of issues, including health care and welfare. Partisan sparks flew early and often between Republican Gov. Paul LePage and Democratic U.S. Rep. Mike Michaud, who are running in a dead heat in the race, far ahead of independent Eliot Cutler, two weeks before Maine residents go to the polls (10/21). 

Arizona Central-Republic: Ducey, DuVal On Health Care
The two major candidates for governor, Democrat Fred DuVal and Republican Doug Ducey, are answering questions about issues explored in The Arizona Republic's "New Arizona" project. The project identified key issues in building a better Arizona. Today, the fourth in the occasional series, we focus on biotech and health care (10/21).

Kansas City Star: Missouri Senate: Two Doctors, Two Different Views On Medicaid Expansion
The two men running for the Missouri Senate in the 34th District are both doctors. Both cited experiences they had as physicians as motivation to run. But they come down on very different sides of a medically focused debate in Missouri: whether the state should expand Medicaid as envisioned in the federal Affordable Care Act. Rob Schaaf, the incumbent in the 34th District, which includes Platte County, said that expanding Medicaid in Missouri would be too expensive for the state. Robert Stuber said that expanding Medicaid is one of his top priorities. Doing so, he said, would create more jobs and salaries, which would increase state tax revenue. Refusing to expand Medicaid, he said, puts rural health care systems at risk for a hefty financial burden as federal subsidies to rural hospitals decrease (Pointer, 10/21).

Oregonian: State Announced $150,000 Contract To Wife Of Key Kitzhaber Adviser Before Competitive Bidding
Oregon Health Authority officials announced the selection of the wife of a former top aide to Gov. John Kitzhaber for a $150,000 contract before any formal bidding took place, The Oregonian has learned. A state manager internally announced the hiring of Kate Raphael to produce videos about the governor's health reforms on July 31, documents show. That was eight days before a formal competitive-bidding solicitation was issued, and nearly a month before a contract was signed (Budnick, 10/21).

Los Angeles Times: Lawyers Versus Doctors In Costly Prop. 46 Campaign Wars
A ballot initiative that pits lawyers against doctors has set off one of this year's fiercest campaign wars, a costly clash over increasing state limits on malpractice damages and imposing drug testing on physicians. Proposition 46 would raise the cap on pain-and-suffering awards in malpractice lawsuits and require that hospitals randomly test their doctors for drug and alcohol use. Backers say the measure would rein in negligent doctors; opponents charge that it's a money grab by the lawyers who helped put it on the ballot (Mason, 10/21).

Miami Herald: Miami Physician Assistant Gets 15 Years For Nation’s Biggest Medicare Therapy Scam
A Miami physician's assistant who was described by his lawyer as a “bit player” in a nearly $200 million mental health scheme to swindle Medicare was sentenced to 15 years in prison on Tuesday. But it could have been worse for Roger Bergman, 65, of Miami, who was facing up to 25 years under federal sentencing guidelines for his supporting role in the biggest mental-health clinic scam ever orchestrated against the taxpayer-funded Medicare program. Bergman, convicted in July of a fraud conspiracy, conducted bogus evaluations of hundreds of patients and falsified their records to dupe Medicare into believing they needed the costly therapy services, according to trial evidence (Weaver, 10/21).

Philadelphia Inquirer: Overdose Deaths Rise In Pa., N.J.
Because of that surge, New Jersey's ranking in drug-death rates soared from 41st in 2010 to 18th. The new statistics predate New Jersey's most recent moves to attack the problem. Several months ago, it changed state law to encourage people who witness an overdose to call 911 without fear of arrest. It also permitted first responders, family, and friends to carry medication that can quickly reverse an overdose due to heroin or opioid prescription painkillers. Families and police around the state have since reported more than 230 "saves," according to the Drug Policy Alliance, including 47 in Camden (Sapatkin, 10/21).

Modern Healthcare: Ky. Cardiologists Settle False Claims Allegations
Two Kentucky cardiologists have agreed to pay $380,000 to settle allegations that they violated the False Claims Act by entering into bogus management agreements with an area hospital in exchange for referring their patients to that hospital, the Department of Justice announced Tuesday. The government alleged that Drs. Satyabrata Chatterjee and Ashwini Anand, who owned cardiology physician group Cumberland Clinic, London, Ky., entered into sham management agreements with Saint Joseph Hospital. The two were paid to provide management services but never actually provided them, according to the government. Instead, they allegedly agreed to refer their clinic's patients to the hospital for cardiology and other services in violation of the Stark Law and the anti-kickback statute, according to a Department of Justice news release (Schencker, 10/21).

Connecticut Mirror: Public Gets First Look At Health Industry Payments To Doctors
Pharmaceutical companies and medical-device manufacturers paid more than $6 million to about 5,400 Connecticut doctors for various services during the last five months of 2013, a Connecticut Mirror examination of a newly released federal database shows. The information was collected under a provision of the Affordable Care Act that is designed to help consumers understand the financial relationships between the health care industry and the nation’s physicians. Though only a five-month snapshot, the new data provides the public with the ability to  search actual payments to their own doctors for the first time (Radelat, 10/22).

Categories: Health Care

Coburn Issues 'Wastebook' That Includes 'Unnecessary' Spending At NIH

Kaiser Health News - Wed, 10/22/2014 - 9:21am

Oklahoma Republican Sen. Tom Coburn's list includes various programs that continue to receive funding even as National Institutes of Health officials express concern about the slowing of disease research.

Politico: Tom Coburn Skewers NIH In Final 'Wastebook'
This particular study on rodent rubdowns cost $387,000 -- a tiny fraction of the National Institute of Allergy and Infectious Diseases’ more than $4 billion budget. But the ranking member of the Senate’s Homeland Security and Governmental Affairs Committee cites many “unnecessary” spending programs that continue while NIH officials argue that important disease research has slowed (Everett, 10/22).

Also in the news, another congressional committee is examining possible waste in the Medicare Advantage program --

Center for Public Integrity: GAO Takes On Medicare Advantage Spending
A Congressional committee has taken aim at waste in the popular Medicare Advantage health insurance program for seniors, ordering an extensive audit of billing errors and overcharges by insurers -- mistakes estimated to cost taxpayers billions of dollars every year. The Government Accountability Office, the watchdog arm of Congress, is conducting the probe at the request of the House Ways and Means Committee. Results are due next spring (Schulte, 10/20).

Categories: Health Care

Poll: Most Likely Voters Expect The GOP To Win Control Of Senate

Kaiser Health News - Wed, 10/22/2014 - 9:20am

Health care continues to be a big issue, though not as important as the economy.

The Associated Post: AP-GfK Poll: Most Expect GOP Victory In November
But the survey suggests many will cringe when they cast those ballots. Most likely voters have a negative impression of the Republican Party, and 7 in 10 are dissatisfied by its leaders in Congress. … What’s deeply important to likely voters after the economy? About three-quarters say health care, terrorism, the threat posed by the Islamic State group and Ebola (10/21).

Meanwhile, MPR examines the ideas for replacing the health care law put forward by Republican Senate candidate Mike McFadden -

Minnesota Public Radio: Experts Say McFadden’s Health Insurance Ideas Don’t Hold Up
Republican Senate candidate Mike McFadden takes advantage of every opportunity to slam the Affordable Care Act as bad for the nation. In advocating for a replacement for the federal health care law, McFadden opposes a national solution. He would leave most of the decisions up to states, including whether to require people to buy health insurance. But McFadden would force states to keep some of the most popular benefits of the heath care law. ... Experts, however, say much of what McFadden proposes has been tried before and left millions of Americans without health insurance (Zdechlik, 10/22).

Categories: Health Care

Public Worres About Ebola Increase Faster Than Cases

Kaiser Health News - Wed, 10/22/2014 - 9:20am

A Pew Research Center survey finds 41 percent of Americans say they worry they or someone in their families will be "exposed" to the Ebola virus, up from 32 percent two weeks ago. Public confidence in the government's ability to combat the disease has also dropped, finds a Gallup poll. Meanwhile, GOP doctors in the House of Representatives seek a temporary travel ban for West African countries affected by Ebola.

Los Angeles Times: Public Concerns About Ebola Increase Faster Than Cases
Public concerns about Ebola have grown much faster than the actual number of cases of the illness in the U.S. A Pew Research Center survey released Tuesday found that 41% of Americans said they worried that they or someone in their families would be "exposed" to the Ebola virus, up from 32% two weeks ago (Lauter, 10/21).

Politico: Poll: Drop In Faith In Government On Ebola
Americans have become less confident in recent weeks in the federal government’s ability to fight Ebola in the United States, according to a new poll. According to the Gallup poll, 52 percent of Americans said that they were “very” or “somewhat confident” in the government’s ability to handle the virus. That’s down nine percent from Oct. 5, when 61 percent of Americans expressed confidence, and Oct. 12, when Gallup found that 60 percent of Americans were confident in government to handle the situation (Breitman, 10/22). 

Politico: GOP Doctors In House Seek Travel Ban
The Republican Doctors Caucus is calling on the White House to put in place a temporary travel ban for West African countries affected by Ebola. The letter, sent Tuesday to President Barack Obama, was signed by 16 members of the group, including co-chairs Reps. Phil Gingrey of Georgia and Phil Roe of Tennessee (Topaz, 10/22). 

USA Today: West Africa Travelers Must Go To 1 Of 5 Airports
The Department of Homeland Security announced Tuesday that all travelers from Ebola outbreak countries in West Africa will be funneled through one of five U.S. airports with enhanced screening starting Wednesday. Customs and Border Protection within the department began enhanced screening — checking the traveler's temperature and asking about possible exposure to Ebola — at New York's John F. Kennedy International Airport on Oct. 11 (Jansen, 10/21).

Categories: Health Care

Hospitals' Purchase Of Doctors' Practices Boosts Costs, Study Finds

Kaiser Health News - Wed, 10/22/2014 - 9:19am

Hospital ownership of physician groups increased patient care costs by as much as 20 percent, according to the UC Berkeley study. Meanwhile, another study by Harvard researchers finds that switching to for-profit status may boost hospitals' financial health but has no effect on quality of care.

Los Angeles Times: Medical Costs Up To 20% Higher At Hospital-Owned Physician Groups, Study Finds
Raising fresh questions about healthcare consolidation, a new study shows hospital ownership of physician groups in California led to 10% to 20% higher costs overall for patient care. The UC Berkeley research, published Tuesday in the Journal of the American Medical Association, illustrates the financial risks for employers, consumers and taxpayers as hospital systems nationwide acquire more physician practices (Terhune, 10/21). 

Modern Healthcare: Hospitals Switching To For-Profit See No Drop In Quality
Switching to for-profit status generally boosts hospitals financial health and has no effect—good or bad—on the quality of care they deliver, according to a new analysis of what happened in the years after more than 200 conversions.  “For-profit hospitals have often argued that conversion will provide resources that will lead to better care,” wrote Harvard University researchers Dr. Karen Joynt, Dr. Ashish Jha and John Orav in a study published in JAMA. “Our study failed to find any evidence to support this notion,” they concluded. ... Some states have limited the entry of for-profit hospital operators out of fear that the profit motive would undermine hospitals' quality and their commitment to serving the uninsured and patients covered by Medicare and Medicaid (Rice, 10/21).

In other hospital news -

Kaiser Health News: Hospitals’ Struggles To Beat Back Familiar Infections Began Before Ebola Arrived
While Ebola stokes public anxiety, more than one in six hospitals — including some top medical centers — are having trouble stamping out less exotic but sometimes deadly infections, federal records show. Nationally, about one in every 25 hospitalized patients gets an infection, and 75,000 people die each year from them—more than from car crashes and gun shots combined. A Kaiser Health News analysis found 695 hospitals with higher than expected rates for at least one of the six types of infections tracked by the federal Centers for Disease Control and Prevention. In 13 states and the District of Columbia, a quarter or more of hospitals that the government evaluated were rated worse than average for at least one infection category, the KHN analysis found (Rau, 10/21).

Categories: Health Care

Kasich's Public Medicaid Expansion Fracas Moves Into Its Second Day

Kaiser Health News - Wed, 10/22/2014 - 9:19am

The Ohio governor is engaged in a spat with The Associated Press after the news outlet published comments in which he said he didn't think the health law would be repealed. He has since offered further explanation, saying that he doesn't think the Medicaid expansion -- which he views as separate from the overhaul -- should be undone.

Politico: Gov. John Kasich’s View On Medicaid Fuels Two-Day Spat With AP
What, exactly, is Obamacare? According to Ohio Gov. John Kasich, it doesn’t include Medicaid expansion, a major facet of the law. It’s a view held by virtually no one else. Kasich’s unorthodox view of the Affordable Care Act — and the hunger the Republican base has for the health law’s repeal — are behind a two-day public spat between the possible 2016 contender and The Associated Press (Wheaton, 10/21).

Meanwhile, in Tennessee, health advocates press for expanding Medicaid -

The Associated Press: Advocates Continue Call For Medicaid Expansion
Members of the state chapter of the NAACP and other health care advocates held a mock funeral across from the state Capitol on Tuesday to characterize lives they say will be lost if Medicaid is not expanded in Tennessee. About 100 people attended the event, which included a processional with a casket. Organizers say many people have died because they don't have health care and that there will be more deaths if Medicaid is not expanded. "The suffering is profound," said Margaret Ecker, an outreach coordinator with the Tennessee Justice Center, a leading advocate for enrollees in TennCare, Tennessee's version of Medicaid. "These are human beings who will all care for. It's about doing the right thing." Gov. Bill Haslam, a Republican, has been criticized by Democrats for refusing last year to agree to $1.4 billion in federal funds to cover about 180,000 uninsured Tennesseans under the terms the money was offered (Johnson, 10/21).

Categories: Health Care

Report Finds Wide Variations Among States In Exchange Plans' Covered Benefits

Kaiser Health News - Wed, 10/22/2014 - 9:18am

University of Pennsylvania researchers find that the variations are significant. Other news about the online health marketplaces that open next month include Oregon's decision to ditch the old system for Medicaid enrollment, a review of navigators' roles in Georgia and Maryland officials' assurances that their system will be read.

Politico Pro: Wide State Differences Seen In Obamacare EHBs
ACA exchange enrollees in almost every state will find that chiropractic care is a covered benefit under their health plan, but they won’t have as much luck with acupuncture and weight loss programs, a new report from University of Pennsylvania researchers shows. The report, which was funded by the Robert Wood Johnson Foundation, finds that significant state variation exists in the ACA essential health benefits that insurers must cover to offer plans on the exchanges (Pradhan, 10/21).

Georgia Health News: Navigators Aided Consumers In Need, Report Shows
Consumers in Georgia and three other states who were helped by navigators for the 2014 insurance exchanges tended to be people of color who were not financially secure, a recently released report says. Navigators, who are specially trained in the provisions of the Affordable Care Act, provide face-to-face, in-person help for consumers seeking information about health insurance policies in the state exchanges, also called marketplaces (Miller, 10/21).

Denver Post:  Disconnect For Health Consumers In Colorado Who Passed On Insurance Through State Exchange
A sign placed out on the 16th Street Mall beckoned people in late March to sign up for health insurance through the Affordable Care and Connect for Health Colorado. Colorado was one of 16 states that set up its own health insurance exchange under the Affordable Care Act and one of 27 states to expand Medicaid. Between the two, Colorado had enrolled more than 300,000 in one or the other by March 31. Among the state exchanges, Colorado had the fourth-highest number of people sign up for private insurance through its marketplace, Connect for Health Colorado. That was estimated to be 25 percent of eligible individuals. The Colorado Health Foundation hired the RAND Corporation to study why the rest hadn't signed up. The foundation released the report, "Barriers to Enrollment in Health Coverage in Colorado," in mid-October (Draper, 10/21).

Baltimore Sun: Md. Is In ‘Good Shape’ For Health Exchange, Official Says
Less than three weeks before uninsured Marylanders get their first look at health plans offered under the Affordable Care Act, officials say preparations are on track. The state's health exchange website crashed on its first day last year and tangled thousands in technological troubles for months. But in a briefing to members of the exchange board Tuesday, the site's top technical officer said it has been fully revamped and appears to be working properly. Though preparations continue, tests show it can handle thousands of users at a time and complex cases (Cohn, 10/21).

Kansas City Star: Coming Soon: Obamacare Take II
It was a near disaster last year when the Affordable Care Act’s health insurance plan marketplaces opened for business. The healthcare.gov website for online enrollment crashed on day one. Political opponents rose in a gleeful chorus of “I told you so.” The public was frustrated and confused. But ultimately, more than 7 million people enrolled in the ACA’s health insurance plans, meeting original predictions. Now, it’s time for round two. Open enrollment for the ACA’s 2015 marketplace insurance plans starts Nov. 15. And this time, the organizations promoting enrollment are optimistic it will go a lot more smoothly. The regional coalition of foundations, social service organizations and safety net clinics will try to better coordinate their work and focus on groups — African-Americans, Latinos, the LGBT community, rural residents — that have been hard to reach (Bavley, 10/21).

Salem Ore. Statesman Journal: Oregon Seeking To Use Different State's Medicaid System
The state has cut its final ties between Cover Oregon and Oracle, the company that was hired to build Oregon's state health insurance exchange. After the two entities failed to launch a working insurance marketplace, the state distanced itself from Oracle and instead piggy-backed on the federal health care exchange for private insurance. Oregon officials had hoped to build on existing work of Oracle's to create an automated system for Medicaid enrollments, but continued disagreements have led to the state giving up on any plans involving the corporation. ... A list of criteria are being developed to help guide the decision on which state Medicaid system to use (Yoo, 10/21).

The Oregonian: Oregon Gives Up On Oracle Technology, Will Use Another State's Medicaid System
State officials have given up on trying to salvage a portion of the troubled Cover Oregon technology project, essentially abandoning all hope of getting any lasting benefit from the $240 million paid Oracle America on the health insurance exchange and related work. ... The state had been planning to use salvaged Oracle technology for enrollment in the Oregon Health Plan, but has now halted that effort (Budnick, 10/21).

The Washington Post: Obamacare’s Small-Business Exchanges To See Major Changes In The Coming Months
One year in, the new small-business insurance marketplaces born out of the new federal health-care law have fallen short of their promise in nearly every state, both in terms of functionality and enrollment. However, many are scheduled to see some important updates heading into year two — ones that health officials say should make them much more useful and appealing to small employers and their workers (Harrison, 10/20).

Categories: Health Care

Employers Devise Strategies To Avoid Obamacare Fines

Kaiser Health News - Wed, 10/22/2014 - 9:17am

With large companies facing potential fines next year for not offering health insurance, some are looking at approaches such as enrolling employees in Medicaid, reports The Wall Street Journal. Meanwhile, the federal government posts a notice Tuesday saying that it will continue to fund an optional health insurance program for the working poor in 2016.

The Wall Street Journal: Companies Try To Escape Health Law’s Penalties
With companies set to face fines next year for not complying with the new mandate to offer health insurance, some are pursuing strategies like enrolling employees in Medicaid to avoid penalties and hold down costs. The health law’s penalties, which can amount to about $2,000 per employee, were supposed to start this year, but the Obama administration delayed them until 2015, when they take effect for firms that employ at least 100 people (Wilde Mathews and Jargon, 10/21).

Modern Healthcare: Feds Outline Plan To Pay States For Basic Health Program In 2016
The federal government will continue to fund an optional health insurance program for the working poor in 2016 with the methodology it used for 2015, according to a proposed notice from the CMS.  The Patient Protection and Affordable Care Act established the Basic Health Program. The initiative is a form of managed care that gives people younger than 65 who earn between 138% and 200% of the federal poverty level and are not otherwise eligible for Medicaid a chance to obtain affordable health coverage. The Basic Health Program is voluntary, and it's an alternative to the widely followed insurance marketplaces. States that move forward with the Basic Health Program must offer plans that at least cover the 10 essential health benefits required by the healthcare law, such as hospitalization, lab tests and mental health services (Herman, 10/21).

Categories: Health Care

Viewpoints: Fund CHIP; Media Overdrive On Ebola; Slowdown In Medicare Costs

Kaiser Health News - Wed, 10/22/2014 - 9:17am

Los Angeles Times: Children's Health Insurance Program Deserves Funding
In what may be a hopelessly quixotic effort, supporters of the federal Children's Health Insurance Program are trying to persuade Congress to renew its funding almost a year in advance — and in a lame-duck session. Nevertheless, lawmakers ought to heed that call. The program plugs a troubling gap between Medicaid and the Affordable Care Act's subsidized plans, and states need to know whether they can count on federal funding or whether they will have to spend far more dollars of their own (10/21). 

The New York Times: The Democratic Panic
But one of the reasons for [President Obama's] unpopularity is that nervous members of his own party have done a poor job of defending his policies over the nearly six years of his presidency, allowing a Republican narrative of failure to take hold. … Similarly, the Affordable Care Act, one of the most far-reaching and beneficial laws to have been passed by Congress in years, gets little respect even among the Democratic candidates who voted for it. Though none support the Republican position of repeal, most talk about the need to “fix” the health law, as if it were a wreck alongside the road rather than a vehicle providing millions of people with health coverage (10/21).

Bloomberg: Republicans Who Secretly Love Obamacare
Here's a conundrum for Republicans this year: The Affordable Care Act remains unpopular, especially with the Republican base, but as the law has taken effect a number of provisions are embraced by voters. Republican candidates across the country, facing this contradiction, have a solution: repeal Obamacare, but keep the popular parts. Never mind this isn't possible; if you get rid of the whole the parts go, too, and few political opponents have proposed an alternative (Albert R. Hunt, 10/21). 

The Washington Post’s Right Turn: GOP 2016 Contenders: Repeal Obamacare, Reform Medicaid
[Ohio Gov. John] Kasich, however, is correct that one can be for repealing Obamacare and still support states’ expansion of Medicaid. But other governors should be forewarned: You better be crystal clear about what you want to do (Jennifer Rubin, 10/21).

USA Today: In Ebola Outbreak, Worry About The Right Things
If you spend enough of your day watching certain cable news outlets without an appropriate degree of skepticism, you easily could become convinced that an Ebola epidemic is imminent, that we are all at tremendous risk of infection. This is extremely unlikely to be true, but while we should not be panicking about the threat of Ebola, we should be panicking about the apparent inability of our institutions to respond appropriately to a genuine public health problem (Duncan Black, 10/21).

Politico: The Hottest Zone: How The Media Stoked The U.S. Ebola Panic.
The irony, at least for Americans, is that only two people have become infected on U.S. soil, and only one of all those treated here has died, while the list of Americans affected by other (more mundane) major health threats is much longer. The press, however, has turned Ebola coverage into a self-perpetuating frenzy. The media keeps making waves and then surfs them in every direction. No question there’s an overwrought panic over Ebola in the United States, and no question the media has played a major role in generating that panic (Tara Haelle, 10/21).

Politico: Are Hospitals More Deadly Than Ebola?
We’ve all been horrified by the medical blunders made in dealing with Ebola in the United States—from sending home a patient who was showing symptoms and had recently travelled to West Africa to relying on inadequate protocols or protection that led to the infection of two of his nurses. It’s awful, but we shouldn’t be surprised. These types of hospital mistakes—caused by knowledge gaps, carelessness, unpreparedness or a combination of all—by my estimate kill between 210,000 and 440,000 people in the United States every year (John T. James, 10/21).

Bloomberg: Let People Shop For Health Care
If people knew the prices of medical treatments, and if they paid partly from their own pockets, they might shop around and save money. This stands to reason, and a new study in the Journal of the American Medical Association shows it's true. This comes as very encouraging news for the wider effort to keep going the profound deceleration in health costs we've seen over the past several years (Peter R. Orszag, 10/21).

Health Affairs: The $500 Billion Medicare Slowdown: A Story About Part D
A great deal of analysis has been published on the causes of the health care spending slowdown system-wide — including in the pages of Health Affairs. Much attention in particular has focused on the remarkable slowdown in Medicare spending over the past few years, and rightfully so: Spending per beneficiary actually shrank (!) by one percent this year (or grew only one percent if one removes the effects of temporary policy changes). Yet the disproportionate role played by prescription drug spending (or Part D) has seemingly escaped notice. Despite constituting barely more than 10 percent of Medicare spending, our analysis shows that Part D has accounted for over 60 percent of the slowdown in Medicare benefits since 2011 (beyond the sequestration contained in the 2011 Budget Control Act). (Loren Adler and Adam Rosenberg, 10/21).

JAMA Internal Medicine: Lowering Medical Costs Through The Sharing Of Savings By Physicians And Patients
Current approaches to controlling health care costs have strengths and weaknesses. We propose an alternative, "inclusive shared savings," that aims to lower medical costs through savings that are shared by physicians and patients. Inclusive shared savings may be particularly attractive in situations in which treatments, such as those for gastric cancer, are similar in clinical effectiveness and have modest differences in convenience but substantially differ in cost. Inclusive shared savings incorporates features of typical insurance coverage, shared savings, and value-based insurance design (Harald Schmidt and Ezekiel J. Emanuel, 10/20).

Categories: Health Care

Longer Looks: Obamacare In The Midterm Campaign; Watching Ebola Mutate; Lessons On Dying

Kaiser Health News - Wed, 10/22/2014 - 9:17am

Each week, KHN's Shefali Luthra finds interesting reads from around the Web.

The Economist: Obamacare And The Midterms
According to Kantar Media, a firm that tracks political advertising, health care is the main subject of campaign ads, especially Republican ones. Obamacare is unpopular—over half of Americans disapprove of it. Republicans talk about it constantly on the campaign trail, though not as intemperately as they did during their own party’s primaries. Democrats scarcely mention it (10/18).

The New Yorker: The Ebola Wars: How Genomics Research Can Help Contain The Outbreak
Within the inner sleeve of an Ebola particle, invisible even to a powerful microscope, is a strand of RNA, the molecule that contains the virus’s genetic code, or genome. The code is contained in nucleotide bases, or letters, of the RNA. These letters, ordered in their proper sequence, make up the complete set of instructions that enables the virus to make copies of itself. A sample of the Ebola now raging in West Africa has, by recent count, 18,959 letters of code in its genome; this is a small genome, by the measure of living things. Viruses like Ebola, which use RNA for their genetic code, are prone to making errors in the code as they multiply; these are called mutations. Right now, the virus’s code is changing. As Ebola enters a deepening relationship with the human species, the question of how it is mutating has significance for every person on earth (Richard Preston, 10/21).

Vox: 9 Lessons Atul Gawande Taught Me About Dying
When I was a kid, I had an overwhelming fear of death. It was the kind of terror that you can't be talked down from, the kind of terror you can only hope to eventually learn to ignore. I became compulsive about avoiding the subject. I would close books when it came up. I would leave rooms when it was discussed. I developed obsessive mental protocols to manage the fear. When I would hear the word "death," I would automatically think, "no death," as if casting a counterspell. "Dying?" "No dying." "Dead?" "No dead." Death was too big a topic to simply ignore. It had to be banished. It had to be fought. I have an easier time talking about death now, but I wouldn't call it a favored topic. So I was a bit apprehensive when I sat down to talk with Atul Gawande (Ezra Klein, 10/21).

The Atlantic: When Health Ignorance Is Bliss
You can't tell that Katrina Walker has a 50 percent chance of having a disease that could kill her in the next couple of decades. The 28-year-old Michigan native likes to paint, read, and watch hockey; she recently posted on Facebook looking for manicure recommendations; she's married, without kids, and is an activity assistant at a skilled nursing center. Walker might also have Huntington's disease, a degenerative disease that her mom has, giving her a 50 percent chance of having the Huntington’s gene. Huntington’s causes nerve cells in the brain to break down, and typically hits between the ages of 30 and 50, starting with mood changes and depression. In its latest stage it can cause an inability to speak or make voluntary movements. Most people diagnosed with Huntington's die from complications of the disease, such as choking and pneumonia, on average 10 to 20 years after the onset of symptoms. Walker could take a test to find out if she has the gene, but she hasn't yet (Jon Fortenbury, 10/21).

Modern Healthcare: At Home With The Specialist: Oncologists And Other Specialists Launching Patient-Centered Medical Homes
Despite tensions between primary care and specialist groups, a growing number of specialist practices, insurers and health systems are moving toward the specialist-based medical home model. But much depends on more insurers paying for the extra services. The NCQA's patient-centered medical home recognition program has about 8,400 participants, mostly primary-care practices. Its Patient-Centered Specialty Practice recognition program, launched in March 2013, has gotten off to a slow start, however. Tampa, Fla.-based HealthPoint Medical Group was the first to gain recognition in February. Thirty other specialty practices have since followed. The list includes 10 oncology, four endocrinology and two cardiology groups (Andis Robeznieks, 10/18).

Categories: Health Care

First Edition: October 22, 2014

Kaiser Health News - Wed, 10/22/2014 - 7:14am

Today's early morning highlights from the major news organizations, including reports about a new poll finding that that most likely voters expect GOP victories in November and that health care continues to be an important issue.

Kaiser Health News: Hospitals’ Struggles To Beat Back Familiar Infections Began Before Ebola Arrived
Kaiser Health News staff writer Jordan Rau reports: “While Ebola stokes public anxiety, more than one in six hospitals — including some top medical centers — are having trouble stamping out less exotic but sometimes deadly infections, federal records show. Nationally, about one in every 25 hospitalized patients gets an infection, and 75,000 people die each year from them—more than from car crashes and gun shots combined. A Kaiser Health News analysis found 695 hospitals with higher than expected rates for at least one of the six types of infections tracked by the federal Centers for Disease Control and Prevention. In 13 states and the District of Columbia, a quarter or more of hospitals that the government evaluated were rated worse than average for at least one infection category, the KHN analysis found” (Rau, 10/21). Read the story, which also ran on NPR. Check out the related chart showing infection rates by state or the downloadable hospital data.

The Associated Post: AP-GfK Poll: Most Expect GOP Victory In November
But the survey suggests many will cringe when they cast those ballots. Most likely voters have a negative impression of the Republican Party, and 7 in 10 are dissatisfied by its leaders in Congress. … What’s deeply important to likely voters after the economy? About three-quarters say health care, terrorism, the threat posed by the Islamic State group and Ebola (10/21).

The Wall Street Journal: Companies Try To Escape Health Law’s Penalties
With companies set to face fines next year for not complying with the new mandate to offer health insurance, some are pursuing strategies like enrolling employees in Medicaid to avoid penalties and hold down costs. The health law’s penalties, which can amount to about $2,000 per employee, were supposed to start this year, but the Obama administration delayed them until 2015, when they take effect for firms that employ at least 100 people (Wilde Mathews and Jargon, 10/21).

Politico: Gov. John Kasich’s View On Medicaid Fuels Two-Day Spat With AP
What, exactly, is Obamacare? According to Ohio Gov. John Kasich, it doesn’t include Medicaid expansion, a major facet of the law. It’s a view held by virtually no one else. Kasich’s unorthodox view of the Affordable Care Act — and the hunger the Republican base has for the health law’s repeal — are behind a two-day public spat between the possible 2016 contender and The Associated Press (Wheaton, 10/21).

The Washington Post: Obamacare’s Small-Business Exchanges To See Major Changes In The Coming Months
One year in, the new small-business insurance marketplaces born out of the new federal health-care law have fallen short of their promise in nearly every state, both in terms of functionality and enrollment. However, many are scheduled to see some important updates heading into year two — ones that health officials say should make them much more useful and appealing to small employers and their workers (Harrison, 10/20). 

Los Angeles Times: Medical Costs Up To 20% Higher At Hospital-Owned Physician Groups, Study Finds
Raising fresh questions about healthcare consolidation, a new study shows hospital ownership of physician groups in California led to 10% to 20% higher costs overall for patient care. The UC Berkeley research, published Tuesday in the Journal of the American Medical Assn., illustrates the financial risks for employers, consumers and taxpayers as hospital systems nationwide acquire more physician practices (Terhune, 10/21). 

Politico: Tom Coburn Skewers NIH In Final ‘Wastebook’
This particular study on rodent rubdowns cost $387,000 — a tiny fraction of the National Institute of Allergy and Infectious Diseases’ more than $4 billion budget. But the ranking member of the Senate’s Homeland Security and Governmental Affairs Committee cites many “unnecessary” spending programs that continue while NIH officials argue that important disease research has slowed (Everett, 10/22).

The Associated Press: CVS Tacks Tobacco Payment To Prescription Network
First, CVS Health pulled tobacco from its store shelves. Now, it plans to make some customers think twice about filling prescriptions at other stores that sell smokes. The nation’s second-largest drugstore chain is developing a new tobacco-free pharmacy network that it will offer as a choice to employers and other clients of its Caremark pharmacy benefits management business. Employers, insurers and unions hire pharmacy benefits managers, or PBMs, to run their prescription drug coverage (10/21). 

Los Angeles Times: Public Concerns About Ebola Increase Faster Than Cases
Public concerns about Ebola have grown much faster than the actual number of cases of the illness in the U.S. A Pew Research Center survey released Tuesday found that 41% of Americans said they worried that they or someone in their families would be "exposed" to the Ebola virus, up from 32% two weeks ago (Lauter, 10/21).

Politico: Poll: Drop In Faith In Government On Ebola
Americans have become less confident in recent weeks in the federal government’s ability to fight Ebola in the United States, according to a new poll. According to the Gallup poll, 52 percent of Americans said that they were “very” or “somewhat confident” in the government’s ability to handle the virus. That’s down nine percent from Oct. 5, when 61 percent of Americans expressed confidence, and Oct. 12, when Gallup found that 60 percent of Americans were confident in government to handle the situation (Breitman, 10/22). 

Politico: GOP Doctors In House Seek Travel Ban
The Republican Doctors Caucus is calling on the White House to put in place a temporary travel ban for West African countries affected by Ebola. The letter, sent Tuesday to President Barack Obama, was signed by 16 members of the group, including co-chairs Reps. Phil Gingrey of Georgia and Phil Roe of Tennessee (Topaz, 10/22). 

USA Today: West Africa Travelers Must Go To 1 Of 5 Airports
The Department of Homeland Security announced Tuesday that all travelers from Ebola outbreak countries in West Africa will be funneled through one of five U.S. airports with enhanced screening starting Wednesday. Customs and Border Protection within the department began enhanced screening — checking the traveler's temperature and asking about possible exposure to Ebola — at New York's John F. Kennedy International Airport on Oct. 11 (Jansen, 10/21).

The Associated Press: Sparks Fly Throughout Last Maine Governor Debate
The three candidates for governor clashed Tuesday in their final debate, highlighting their differences on a wide range of issues, including health care and welfare. Partisan sparks flew early and often between Republican Gov. Paul LePage and Democratic U.S. Rep. Mike Michaud, who are running in a dead heat in the race, far ahead of independent Eliot Cutler, two weeks before Maine residents go to the polls (10/21). 

Los Angeles Times: Lawyers Versus Doctors In Costly Prop. 46 Campaign Wars
A ballot initiative that pits lawyers against doctors has set off one of this year's fiercest campaign wars, a costly clash over increasing state limits on malpractice damages and imposing drug testing on physicians. Proposition 46 would raise the cap on pain-and-suffering awards in malpractice lawsuits and require that hospitals randomly test their doctors for drug and alcohol use. Backers say the measure would rein in negligent doctors; opponents charge that it's a money grab by the lawyers who helped put it on the ballot (Mason, 10/21).

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Categories: Health Care

Hospitals’ Struggles To Beat Back Familiar Infections Began Before Ebola Arrived

Kaiser Health News - Tue, 10/21/2014 - 4:13pm

While Ebola stokes public anxiety, more than one in six hospitals — including some top medical centers — are having trouble stamping out less exotic but sometimes deadly infections, federal records show.

Nationally, about one in every 25 hospitalized patients gets an infection, and 75,000 people die each year from them—more than from car crashes and gun shots combined. A Kaiser Health News analysis found 695 hospitals with higher than expected rates for at least one of the six types of infections tracked by the federal Centers for Disease Control and Prevention.  In 13 states and the District of Columbia, a quarter or more of hospitals that the government evaluated were rated worse than average for at least one infection category, the KHN analysis found.

The missteps Texas Health Presbyterian Hospital made this month in handling an Ebola patient echo mistakes hospitals across the nation have made in dealing with homegrown infections. Dr. Kevin Kavanagh, a patient safety expert from Kentucky, said hospitals too often don't strictly follow protocols to deal with infectious diseases, and the government's standard responses are not specific enough. "Right now there are too many recommendations on how to handle infectious diseases, too much leeway," he said. 

A 2011 study in the New England Journal of Medicine underscored the problem, observing that while hospitals have reduced the frequency of many infections over the last decade, they could do better if staff complied with recommendations. Those include always washing their hands and using maximal barrier procedures when tubes are being inserted, such as covering patients from head to toe with a sterile drape and wearing sterile caps, masks gowns and gloves. 

"The percentage of time that health care providers do all of the things they are supposed to do when caring for a patient with a contagious disease can be pretty low," said one of the authors, Dr. Don Goldmann, chief medical and science officer at the Institute for Healthcare Improvement, a nonprofit in Cambridge, Mass. "There’s a lot of room for improvement."

Goldmann said that hospitals tend to become more focused on following procedures when facing novel, highly publicized outbreaks such as Ebola. "When [an infection risk has] been around for a long time, it kind of becomes part of the background," he said.

Since 2012 the federal government has been analyzing and publishing the CDC rates for specific hospitals on Medicare’s Hospital Compare website. Starting this fall, Medicare is considering infection rates when deciding how much to pay hospitals.

The CDC reports six categories of infections: those from flexible tubes inserted into veins to deliver medicines or nutrients; infections from catheters that drain bladders; two antibiotic resistant germs, Clostridium difficile (C. diff) and Methicillin-resistant Staphylococcus aureus (MRSA); and two surgical site infections after hysterectomies and colon operations. 

States with more than a quarter of hospitals having at least one high infection rate in the CDC data were Arizona, California, Colorado, Connecticut, Florida, Massachusetts, Montana, Nevada, New Jersey, New York, Rhode Island, South Carolina and Utah, according to the KHN analysis of the most current CDC records. 

Infections In Hospitals

Three highly regarded institutions—New York-Presbyterian Hospital in Manhattan, Geisinger Medical Center in Danville, Pa., and the University of Michigan Health System in Ann Arbor—were among seven hospitals the CDC rated as having worse than average rates for four of the six infections, KHN found.

The CDC data, based on reports hospitals submit, are considered the most reliable assessments that exist. Still, many hospitals the CDC judged as having worse than average rates disputed those verdicts. They said that they look bad because they are more vigilant in identifying and reporting infections, or because they handle very sick patients who are more prone to catching a bug. 

For instance, Dr. Darrell Campbell Jr., chief medical officer at the University of Michigan Health System, said hysterectomies are performed on cancer patients at four times the rate than at other Michigan hospitals that compare information with each other. Because cancer surgeries take longer than regular hysterectomies, often involving removal of pelvic lymph nodes, the chances of infection are greater, he said. 

"When you adjusted for the cancer, we don't look different from any of the hospitals," he said. Campbell said none of Michigan’s infection rates deserved being rated poorly.  "Eventually, we'll get where we are more comfortable with this data, but we’re not there now," he said.

New York-Presbyterian said in a statement it has made "significant improvements." Geisinger said in a statement that its infection rates have dropped since 2012 and that its MRSA rate appeared high because the hospital made a "data entry error" when it reported cases to the government. Geisinger also noted that many patients who test positive for C. diff never develop any symptoms, but hospitals still must report it as an infection.

Some major teaching hospitals, like Denver Health Medical Center, Duke University Hospital in Durham, N.C., and Mayo Clinic’s hospitals in Rochester, Minn., have been able to maintain low infection rates, the KHN analysis shows. 

Others are succeeding in controlling some infection types but not others, according to the CDC data. Yale-New Haven Hospital had lower than average rates of bloodstream infections caused by central lines, but higher than average rates of infections from catheters inserted into the bladder to remove urine. Since one of the main ways to avoid such infections is to remove the catheter as soon as it is not essential, the hospital now allows nurses to take them out without a physician’s order under certain conditions, said Dr. John Boyce, the hospital’s director of epidemiology and infection control. "Busy physicians sometimes forget their patient has a catheter in, but the nurses know," he said.

Nationally, surgical site infections dropped by a fifth and central-line infections decreased by 44 percent between 2008 and 2012. MRSA decreased by a third during that period. 

Battling C. diff is very different than fighting Ebola and in some ways harder, because it requires hospitals to restrain use of the antibiotics necessary for so many patients. When those drugs eliminate weaker bacteria from the intestines, C. diff is able to prosper. Patients can get massive diarrhea and, while C. diff can be treated, the worse cases may require surgery to remove the infected part of the intestines.

Other infections for which the CDC tracks but does not yet publish hospital-specific rates, known as gram negative, are impervious to nearly all antibiotics.

Reducing the frequency of C. diff and these kinds of infections requires hospitals to become more judicious in deploying antibiotics. But only about half of hospitals have established stewardship programs that help doctors use the appropriate antibiotics in the most effective doses without overdoing it, researchers say.

"We have increasing amounts of data that thirty to fifty percent of the antibiotics we are prescribing are inappropriate," said Dr. Kavita Trivedi, a consultant and former infection control official for California. "It sounds crazy to people who are not in medicine: Why would a patient be prescribed an antibiotic they don’t need? But it happens frequently because we don’t know what they need."

Data for individual hospitals is available as a Printable PDF and as a CSV spreadsheet, and you can also view infections rates by state.

jra@kff.org

Categories: Health Care

High Infection Rates Vary By State

Kaiser Health News - Tue, 10/21/2014 - 4:12pm

This chart shows what proportion of hospitals in each state had higher than average infection rates for at least one type of infection publicly reported by the Centers for Disease Control and Prevention. The rates are based on infections contracted in the first nine months of 2013 and, for some of the infections, also the last three months of 2012. KHN excluded from the calculations hospitals that did not report any infection rates to the CDC or did not have enough cases for the CDC to evaluate.

<< Back To Main Story: Hospitals’ Struggles To Beat Back Familiar Infections Began Before Ebola Arrived

Categories: Health Care

Ebola Tipping Point? Dispelling Myths And, Possibly, Less Hysteria Over Virus

CommonHealth (WBUR) - Tue, 10/21/2014 - 3:54pm

A World Health Organization worker trains nurses on how to use Ebola protective gear in Freetown, Sierra Leone. (AP)

Has the national hysteria over Ebola peaked? Who knows. Maybe. There seem to be fewer front page headlines screaming about it; a new national poll finds most Americans are “positive” about the response by public health authorities; and today’s news is that more than 40 Dallas residents (all who had been in contact with the Liberian man who died of Ebola) were declared virus free.

Still, education is the antidote to hysteria, so it’s worth reiterating some of the facts. Many of them can be found in this must-read commentary in the London Review of Books by Paul Farmer, the rock star Harvard infectious disease doctor and leading advocate for global health equity in the world’s most impoverished regions.  Farmer, who is also a co-founder of the Boston non-profit Partners in Health, writes that despite some of the truly scary aspects of the virus, an Ebola diagnosis is not necessarily a death sentence:

The Ebola virus is terrifying because it infects most of those who care for the afflicted and kills most of those who fall ill: at least, that’s the received wisdom. But it isn’t clear that the received wisdom is right….

…the fact is that weak health systems, not unprecedented virulence or a previously unknown mode of transmission, are to blame for Ebola’s rapid spread. Weak health systems are also to blame for the high case-fatality rates in the current pandemic, which is caused by the Zaire strain of the virus. The obverse of this fact – and it is a fact – is the welcome news that the spread of the disease can be stopped by linking better infection control (to protect the uninfected) to improved clinical care (to save the afflicted). An Ebola diagnosis need not be a death sentence. Here’s my assertion as an infectious disease specialist: if patients are promptly diagnosed and receive aggressive supportive care – including fluid resuscitation, electrolyte replacement and blood products – the great majority, as many as 90 per cent, should survive.

And he adds this:

I’ve been asked more than once what the formula for effective action against Ebola might be. It’s often those reluctant to invest in a comprehensive model of prevention and care for the poor who ask for ready-made solutions. What’s the ‘model’ or the ‘minimum basic package’? What are the ‘metrics’ to evaluate ‘cost-effectiveness’? The desire for simple solutions and for proof of a high ‘return on investment’ will be encountered by anyone aiming to deliver comprehensive services (which will necessarily include both prevention and care, all too often pitted against each other) to the poor. Anyone whose metrics or proof are judged wanting is likely to receive a cool reception, even though the Ebola crisis should serve as an object lesson and rebuke to those who tolerate anaemic state funding of, or even cutbacks in, public health and healthcare delivery. Without staff, stuff, space and systems, nothing can be done.

If you want to become more educated on Ebola and find out what you can do to support the global effort, Partners In Health/Engage and Harvard are sponsoring an Ebola teach-in Wednesday night in Cambridge with a panel of practitioners and public health experts.

Jon Shaffer, Senior Strategist for Grassroots Organizing at PIH, says the goal of the event is to “help our broader community understand the social, political, biological and economic context in which this epidemic is situated.” Beyond fundraising, which is obviously important, Shaffer says the group is also advocating for a swifter and more aggressive response by the U.S. government to the Ebola epidemic and is also working to dispel myths about the virus.

Categories: Health Care

Direct Democracy: Ties between Switzerland and the U.S.

In Custodia Legis - Tue, 10/21/2014 - 1:44pm

The following is a guest post by Dr. Goran Seferovic. Goran is a senior research associate at the University of Zurich’s Institute of Law and has been our scholar in residence at the Law Library of Congress this past summer. Goran is conducting research on direct democracy and intends to publish a book on this subject. You can read more about Goran in his interview published in In Custodia Legis on October 1st, 2014.

There is a radical difference between a democracy and a representative government. In a democracy, the citizens themselves make the law and superintend its administration; in a representative government, the citizens empower legislators and executive officers to make the law and to carry it out.

James W. Sullivan (1848-1938) (The National Civic Federation Review, Dec. 1, 1913)

These sentences begin the book Direct Legislation by the Citizenship through the Initiative and Referendum, written in 1892 by James W. Sullivan.  Sullivan drew a strong distinction between the representative government and a “direct democracy”, by which he meant a form of government in which the citizens themselves make laws and oversee the administration of the laws. The mechanisms that would enable the citizens to do that, according to Sullivan, were the initiative and the referendum.

In a referendum citizens vote on a law or a constitutional amendment passed by the legislature. The referendum vote can either be mandatory (legislative referendum) or requested by the citizens by collecting a certain number of signatures of citizens (popular referendum). The initiative is the proposal of new laws or constitutional amendments placed on the ballot by collecting a certain number of signatures of citizens (See the National Council of State Legislators homepage).

Sullivan was a printer and editor from Pennsylvania but he was also a leader of the International Typographical Union. Sullivan learned as early as 1874 about direct democracy in Switzerland and about the writings of Karl Burkli from Zurich (Sullivan, supra at ii).

Burkli was one of the early Swiss Socialists. He moved to Texas in 1855 to take part in an endeavor to found a utopian self-sustaining community near a town in Texas called Utopia. However, the project didn’t succeed and Burkli moved back to Zurich. He took part in the movement to end the rule of the liberal majority in Zurich. In 1868 he was elected to the council for the revision of the constitution of Zurich. Being a strong advocate for direct democracy Burkli succeeded in introducing the initiative in its modern form in the constitution of Zurich, one of Switzerland’s cantons (a canton is a member state of the Swiss confederacy). The initiative provision in the constitution of Zurich enabled the citizens of this canton to draft laws and bring them to a public vote thereby circumventing the legislative procedures that are otherwise required to pass legislation by parliament.

Karl Burkli (1823-1901) (Samuel Zurlinden, Hundert Jahre: Bilder aus der Geschichte der Stadt Zürich in der Zeit von 1814-1914, Vol. II, Zurich 1915 at 70)

Burkli proposed a special form of a Swiss Socialism in which direct democracy would in the end lead to a popular government without the need of a parliament. This idea was rejected by the German socialist leaders Marx and Engels. The writings of Burkli were translated into English and distributed though the International Workingmen’s Association (Karl Bürkli, Direct Legislation by the People, Versus Representative Government, Translated from the original Swiss Pamphlets by Eugene Oswald, London 1869).

Sullivan probably became familiar with the Swiss system of direct democracy through his contacts with international labor unions. But Sullivan also travelled to Switzerland and met with Burkli himself. The Central Library of Zurich holds a copy of Sullivan’s book with a dedication for Karl Burkli.

Sullivan was not the only one to write about direct democracy in the United States at that time. Numerous books have been published on the Swiss political system and about direct democracy. But Sullivan’s book was by far the most popular. The publication of his book was timely since the United States changed at the end of the 19th century from an agrarian to an industrialized society. Scholars have noted that large parts of the society could not profit from that development. Accordingly, farmers became poor because their revenue decreased drastically. On the other hand, big industrial and financial companies formed at that time influencing politics to pass legislation favoring their position (see Steven L. Piott, Giving Voters a Voice: The Origins of the Initiative and Referendum in America, 2003). Sullivan’s book has been said to have inspired the movements against these special interests to campaign for the incorporation of direct democracy into the states constitutions (Piott, id. at 3).

Swiss Miss giving the referendum to Lady Liberty. (Dan Beard, Cosmopolitan Magazine, July 1893)

Sullivan argued that the goal of the direct democracy movement was to circumvent the legislators whom he considered “habitually” corrupt and non-responsive to the needs of the people in a society in the transition to an industrial country (Sullivan supra at 95).

However, the movement seems to have only succeeded in parts. While most states in the west incorporated direct democracy into their systems, in the east, the south and at the federal level direct democracy appears to have been largely rejected.

In Switzerland, however, all cantons have incorporated direct democracy into their political systems, and in 1891 the initiative was also introduced at the federal level.

Whether direct democracy achieved its goal of making the state legislators in the United States more responsive to the concerns of the people is a question still debated today (See, e.g., Richard J. Ellis, Democratic Delusions: The Initiative Process in America, 2002).

For further reading you may consult the following sources:

Thomas E. Cronin, Direct Democracy: The Politics of Initiative, Referendum, and Recall, 1989.

Thomas Goebel, A government by the people: Direct democracy in America, 1890-1940, 2002.

 

 

 

 

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