Friday, September 24, 2010

Annual Check-Ups Covered, Among Other Things

This week, a few key pieces of health care reform legislation went into effect, including coverage for preventative care visits. This very concrete change will have a big effect on families, who often coordinate several yearly check-ups for family members. A check-up required for a child to attend school should not cost a family with insurance coverage $200 out of pocket.

Lifetime caps on what health insurance will pay have also been removed, providing more financial security for people with insurance who become seriously ill. Children with pre-existing conditions must be covered by group health care plans as well.

WebMD has a good video interview with HHS Secretary Kathleen Sebelius explaining the changes that went into effect on September 23, and promoting the consumer health care plan website.

These reforms have had some interesting consequences, though. A recent Fierce HealthPayer article pointed out that insurers such as Anthem Blue Cross, Humana, Aetna, Cigna, and UnitedHealthCare, for example, are trying to drop individual insurance plans for children in some parts of the country to avoid the expense of covering children with pre-existing conditions.

With more people getting and using health insurance under the new reforms, I was not surprised to read that the University of California at San Francisco approved funding for a new hospital complex this month. I wonder how many other hospital-building plans are going forward now that there will be more patients with insurance coverage to pay their bills. Will this new influx of patients (and payments) improve hospital care nationwide?

I've also heard rumblings about shortages of primary care doctors and nurses who will be needed to serve these new patients, a problem HHS is trying to remedy with financial incentives for health care providers who can fill this gap. The ongoing nursing shortage in particular seems to be a deeply entrenched problem nationwide.

I wonder what other changes - anticipated or not - health care reform might bring?

Friday, September 17, 2010

Who Makes a Good Doctor?

A recent study in the September 13 issue of the Archives of Internal Medicine found that it's difficult to for patients to accurately measure the quality of care a doctor might provide. The study of 10,408 Massachusetts physicians, along with claims data from over 1 million adults from 2004 to 2005, found that information about doctors that is made available to patients does not reveal much about how good the doctor will be.

The data available to patients includes a doctor's gender, education, certification, and malpractice claim history. The Archives of Internal Medicine study found that doctors who are female, board-certified, and trained in the U.S. provide slightly better care than other doctors, with board certification carrying the most weight. These distinctions, however, were not statistically very large.

Setting aside physicians who should not be practicing medicine because they have abandoned, neglected, or abused their patients, though, I wonder how exactly to define "quality of care" among physicians. In the doctor/patient relationship, different patients value different qualities: some might prefer a doctor who is the same gender as them, or who has a certain bedside manner, or who received training from an institution they admire, or whose office staff are easy to work with.

A patient who has a strained relationship with their doctor might avoid calling or visiting their doctor or revealing some medically-relevant personal information, even when they were ill or needed follow-up care. Even if the doctor provided excellent care, this patient would probably be better off with a less competent doctor who worked with the patient better.

I'm all in favor of the practice of evidence-based medicine, in which treatment decisions are made based on the best available science. But to some extent, "quality of care" is about the quality of the relationship between the patient and the doctor, which is why it is difficult to measure.

In the end, I like The Lancet's take on this topic in its August 28 issue: that the answer to the question "what makes a good doctor?" depends on who is asking it:
The attributes of a good doctor vary according to the population surveyed. Patients value communication and care, colleagues seek competence and camaraderie, medical students prize cheerfulness. By contrast, admission panels focus on chemistry grades, as if knowledge of ionic bonds is somehow a proxy for the complex human and organisational bonds between doctors, their patients, and colleagues.

Friday, September 10, 2010

Education, Not Knowledge, Favors Health

A recent study of HIV education in rural Ghana found that simply telling people how to prevent the spread of HIV might not do much to slow the spread of the disease. The study, published online in Psychological Science, found that people with limited formal education have not always developed the cognitive skills to understand how to stop the spread of HIV.

The study of 181 adults found that a person's level of formal education, rather than a person's knowledge of HIV/AIDS prevention, best predicted whether or not the person took steps to protect themselves from HIV infection.

"About $8.9 billion has been spent on HIV prevention in Ghana and the surrounding region since 2000, primarily through disseminating facts about the disease," stated a recent press release on the study. "But the effectiveness of these programs has never been adequately studied." The study's lead author, Ellen Peters, explained that "Our findings suggest that those effects, however well intentioned they may be, may not be sufficient without efforts to help at-risk adults to reason correctly with the facts they have been taught."

Unfortunately, the connection between health and education works the other way, too: some parasitic illnesses common in the developing world cause cognitive or physical problems that can interfere with a child's ability to attend school, an issue that I've blogged about before.

Numerous studies in wealthier countries have found a link between educational level and health behaviors: the more education someone has, the healthier they tend to be. The Ghana study looked at the developing world and found the same pattern.

The disease burden is enormous in sub-Saharan Africa, where Ghana is located. Sub-Saharan residents, who make up 11% of the world population, "suffer 24 percent of the world's disease burden -- which is addressed with less than 1 percent of the world's health care spending," Nicholas D. Kristof and Sheryl WuDunn wrote in their book Half the Sky: Turning Oppression Into Opportunity for Women Worldwide. About 2% of the population of Ghana has HIV/AIDS, and the country also contends with high rates of malaria and other health problems.

The Ghana study raises some interesting questions. For example, what role can education play in helping people to learn how to prevent or reduce their risk for these diseases? And should some portion of the limited health care budget in sub-Saharan Africa be spent providing a stronger general education to the population, rather than directly on health care services and disease education?

Thursday, September 2, 2010


After the egg recall hit home for me recently and we purged all the eggs, I was faced with a list of family meals for the week that lacked an important ingredient: eggs. Cornbread? Can't make it. I couldn't pack hard-boiled eggs for lunch, either, or cook scrambled eggs with cheese and tortillas for dinner (a family staple on deadline-heavy weeks - dinner in ten minutes!).

Since we don't each much meat, I couldn't turn to steaks and burgers to replace recipes with eggs in them. Instead, we drifted in the other direction, toward vegetarian and vegan meals.

A few months ago, I tried to eat vegan food once a week, after I read an article that suggested that avoiding animal protein might decrease inflammation. Even if this isn't true, I thought, it can't hurt to eat more fruits, vegetables, and whole grains for a day. But I'm no vegan. I had trouble making it through the vegan days, as I craved dairy products too much in all their glorious forms (and craved their protein as well, no doubt).

Out of eggless necessity, though, I went back to my handful of vegan recipes and served an old dinner favorite, a vegan pasta with cauliflower recipe.

That took care of one night.

Then, while I was staring into my refrigerator, I realized that I could buy locally-grown eggs at the Farmer's Market. Eureka! I brought the kids to the market with one mission: find the egg stand. I steered them past the kettle corn and corn on the cob, past the peaches and strawberries, to get in line for the organic brown eggs. Once I had two dozen eggs in my bag, I relaxed. At last.

The spinach pie I made with the eggs later that night had a strong, almost gamey flavor, as I've become used to the more anemic eggs that I buy in the store. But I'll keep going back to the Farmer's Market for eggs, until I'm certain the recall is officially over.