KOLAHUN

Stay (and we'll let you complain) in New Orleans

Sammy Mack writes as fair an article on the subject of private hospitals attempting to recoup costs for the uninsured as possible, in this weeks Gambit Weekly article.  She describes the difficulty private hospitals like West Jefferson and Touro have with the higher percentage of indigent patients within a system where the previous default (Charity Hospital) runs at a very small percentage of its previous capacity.  And the solutions offered by those practitioners and by other interested parties, including increasing Medicaid coverage, medical homes models, attempts at primary care block grants, et. al are all well and reasonable. 

But let's spend a moment on how she describes the initial problem in this city:

"According to a Kaiser Family Foundation study, when Charity was still functional, about half its patient population was uninsured, and Medicaid covered only a third. Local private hospitals cared for only half the national average of uninsured patients who typically get care at private hospitals. Now, without Charity absorbing the uninsured and underinsured of the New Orleans area, the region's private hospitals must serve a very different population than they did prior to the storms " a population that does not have insurance or the means to cover private hospital or physician bills."

Where were these hospitals before the storm?  Cherry picking a bunch of insured patients, leaving indigent patients to the whims of a grossly dysfunctional bureaucratic morass - that's where.  And now that they've had to 'serve the poor,' they're disgruntled.  Sympathy for private practitioners in this circumstance is a little hard to dredge up. 

And yet...we kinda have to.  It'd be nice to just tell these clinicians to "suck it up and deal with it - our city got pummeled and we all have to chip in."  And they did - in the few months after Katrina - only a few hospitals were open (West Jeff, East Jeff and Ochsner) - and none were inside New Orleans proper.  Moreover, these clinicians have choices - if they don't want to be here, they can go elsewhere in the country...and continue the New Orleans' brain drain. 

So yeah - until we have a new health care system not based on private insurance or profit, especially in post-Katrina New Orleans, we're going to have to compensate these guys.  Expand the Disproportionate Share Hospital funds, increase Medicaid eligibility (pass SCHIP!)...whatever. 

Worse than listening to these clinicians would be...not listening to them because they're gone from this city. 

The Flat Earth Medical Society

The Age of Information descending upon us, it's a little scary for the medical guilds who previously had full access to years of medical information.  With Wikipedia, Google, Yahoo easily directing patients with medical questions to reasonable sources and WebMD and Dr. Koop selling services to curious consumers (through advertising), the guild has lost its monopoly on information. 

This explains the abject failure of any attempt to minimize the agreeably noxious practice of direct-to-consumer advertising.  Not only does this proposal marked First Amendment implications, but it also...won't work.  One can't stop the avalanche of information available to medical consumers anymore.

Moreover, this is also true of websites like this wikipedia-for-health-care-workers, AskDrWiki.  It's probably a more beneficial for practitioners and public health stewards to work with and improve these Web2.0 tools.  Not doing so risks turning over information portals to more nefarious actors. 

That being said...it's still a little scary to have a wiki for health information.  Anyone posting anything...anyone editing, correcting, posting - even medical students! 

(At least the advisory board appears to have fairly competent specialty editors.  And they do have some pretty cool stuff on AskDrWiki, including this whole host of EKGs.)

Mental health, shemental health

It's the soft science, the touchy-feely crap, the discipline with a bunch of malingerers...until, of course, one sees a therapist and finds that well, there's a shitload of stuff inside his head that's negatively manifesting in untold ways. 

That being said, here are a couple of post-Katrina mental health updates from RAND.  The first describes the good immediate, but poor medium and long-range response for children in the Gulf Coast region:

"Researchers from RAND Health found that schools in Alabama, Louisiana, Mississippi and Texas were quick to implement a comprehensive approach to assisting students immediately after the storms, enrolling displaced students, getting them books and uniforms, and providing other services, such as one-on-one counseling.

However, within six months of the storms, some schools determined there was no need for those additional services and returned to an emphasis on academics. Other schools felt there was a need for additional mental health services, but either did not have the funding or the properly trained staff, according to the study published in the October issue of Psychiatric Services."

What effects will the lack of services have for New Orleans?  There's a whole host of post-disaster mental health literature of which I have no familiarity, but I'd guess offhand that the lack of services can't be good for the crime statistics (unless one's a criminal, of course) and a community's well-being. 

Which brings up the second RAND update - a fairly large grant to develop community based mental health services:

"The Robert Wood Johnson Foundation has awarded the RAND Corporation a $1.2 million grant for a two-year project to help develop improved, culturally appropriate mental health services in New Orleans.

“New Orleans community members have faced increased stress since the hurricanes of 2005, while also having access to fewer mental health services,” said Dr. Benjamin Springgate, project director and an adjunct scientist at RAND. “Developing additional evidence-based services to promote emotional well-being and resilience is critical to long-term community recovery.”"

Good luck to all.   

SCHIP Resurrection (volume 7)

Coming at you leaner (max family income $61,950) but still mean (with a cigarette tax):

"Speaker Nancy Pelosi said the House would vote Thursday on the new bill. Like the original, which President Bush vetoed three weeks ago, it would cover 10 million children through the State Children’s Health Insurance Program and increase spending on the program by $35 billion, for a total of $60 billion, in the next five years.

But the new bill would tighten eligibility for the program, generally barring the use of federal money to cover illegal immigrants, childless adults and children of families with incomes exceeding three times the poverty level: $61,950 for a family of four.

“The bill addresses all of the concerns that were expressed by our colleagues and by the president,” Ms. Pelosi said. “We hope the Republicans will take yes for an answer.”"

Look, pundits and bloggers have rightly railed this Congress for utter flaccidity.  So good for them for pushing this bill against an intransigent President.  The bill addresses well documented gaps in health care.  It's relatively inexpensive.  It really is for kids.  And the "$80,000" straw-men that the Righties have tried to scare the electorate has been eliminated. 

If you were a Republican, how could you not vote for this bill?  We outlined the Righty arguments against SCHIP here, but at this point, the arguments are falling apart.  No longer can families above 300% qualify - even previously, states needed a special exemption to allow them anyway! - and at lower ends of income, since families/children really don't have medical insurance, they can't switch out of private insurers (the dreaded 'crowd-out' effect).

So at this point, I'll once again proudly predict that

• Bush vetoes this bill and
• Congress overrides him    

Who knew that...

... the good folks from the New York times eat in the Treme:

"In the span of a few hours, I ate fried chicken at both Dooky Chase’s and Willie Mae’s Scotch House. Besides the obvious caloric implications, two orders of fried chicken might not seem like a big deal.

But in the Treme, a neighborhood that took on four or five feet of flood water during Hurricane Katrina, eating fried chicken at both restaurants is a big deal indeed.

The Treme is the oldest settlement of free slaves in the South. It’s not a terribly long walk from the French Quarter, but it’s one tourists rarely took before the storm and they’re sure not taking it now."

Asthma and bacteria

From the October 11, 2007 NEJM, this article gives some new evidence of an old postulate that bacteria may be at the root of childhood asthma.  Basically, researchers in Denmark followed about 400 children over 5 years.  They screened them for common childhood bacterial colonization at 1 month and 12 months of age (and didn't treat if the child had no signs/symptoms of infection) and then followed these children over 5 years to see if any developed early signs/symptoms of asthma.  They then report odds ratios/hazard ratios of the chance of developing asthma in those who were colonized to those who weren't colonized:

The authors then, rightly, conclude that colonization with strep/h.flu/m. catt may leave children at increased odds/hazard of having asthma-like symptoms than those children who were not colonized.  (They found no increased risk with staph, though). 

Now, the obvious next step is to design a study that eradicates these potentially causative organisms and see what happens...and determine how this findings interact with the known environmental and immunologic pathogenesis of asthma.  Maybe then they'll win the Nobel Prize like Barry Marshall and Robin Warren...who discovered the role of h. pylori in peptic ulcer disease.   

Les Miles - my new favorite football coach

Two weeks ago, he went for it on FOUR 4th-and-1s, the LSU Tigers converted on all of them and won. Today, he called a pass play with 11 seconds left in the game, his team down 1 point and already in field goal range.

Result - touchdown LSU. Unbelievable.

Bush's most loyal constituency...Liberia!

Look - it's easy to dump on Bush these days (and I have in the previous post) and while it seems the rest of the world can't stand this guy...he'll always have a home in Liberia.  He did force Charles Taylor to flee to Nigeria in 2003 and PEPFAR really has done a good job of procuring and spreading money in Africa for AIDS treatment.  Apparently, Ellen-Johnson Sirleaf visited him recently:

Bush said Treasury Secretary Henry Paulson would ask the International Monetary Fund at a meeting in Washington this weekend to help relieve Liberia's debt. "It's very important for our friends in the IMF to recognize that debt relief ... for Liberia is a part of our agenda, and I would hope that they would help you," Bush told Sirleaf.

He said the Peace Corps had been in touch with the State Department and Liberian officials about sending volunteers there quickly. And he pledged to implement a U.S. initiative to help battle malaria _ a "death that we can cure" _ in Liberia with nets and insecticide.

"Young babies die on the continent of Africa and elsewhere needlessly _ they die simply because of a mosquito bite," Bush said.

And you know what...he's right.  Good for him.  Good for Liberia. 

SCHIP dies - for now (volume 4)

Well, this makes me want to yell out...but I just end up feeling sad.  Bush's ideology has gotten us into an unnecessary war we can't get out of, re-distributed wealth to the super-rich, antagonized much of the world...and now, it prevents us from passing an extension of health insurance for the poor.  It brings up frustrations of impotence in the Democrat Congress, anger toward the Bush and an overall feeling of sadness towards for this country's future. 

Here's how the NEJM puts it:

"To appreciate the power of the U.S. presidency — even when its current occupant's approval rating is only 31% — one need look no further than the political brawl over the State Children's Health Insurance Program (SCHIP). On October 3, 2007, President George W. Bush vetoed legislation that would have reauthorized SCHIP for 5 years, asserting that it was too expensive and would lead down a path to socialized medicine. On October 18, despite pleas by Democrats and some senior Republican legislators, the House failed to garner the necessary two-thirds vote to override Bush's veto; the vote count was 273 to 156. In addition to many legislators, a large majority of the public, major private stakeholders, and 43 governors strongly support expansion of the program. By contrast, in an effort to appeal to the conservative base of their party, the leading Republican presidential candidates agreed with Bush's veto — despite the fact that the program, though signed into law by a Democratic president, originated in a bipartisan compromise and was enacted by a Republican-controlled Congress. 

A few months ago, reauthorization of SCHIP seemed like a routine matter. Then Bush decided to single it out as a target of the administration's newfound fiscal discipline."

MRSA kills!

The local public stations with Brobson Lutz!), talk radio and the cable news stations have been going nuts over this story - with semi-reasonable cause.  (See the earlier discussion on the original, excellent article here.)   

The human face of MRSA now is Ashton Bonds - who MAY HAVE/PROBABLY HAS died from invasive MRSA infection:

"All 21 school buildings in Bedford County, Va., were being scrubbed and sanitized Wednesday after the death of a 17-year-old high school student from a powerful drug-resistant strain of staph bacteria.

The schools, all in Bedford County, Va., were closed after students there launched a protest over unsanitary conditions Monday, using text messages and social networking sites.

The students took Bedford County Schools Superintendent James Blevins on a tour Tuesday of Staunton River High School to show him how unclean it was, in particular the sports locker rooms.

One of its students, Ashton Bonds, died Monday after being hospitalized for more than a week from Methicillin-resistant Staphylococcus aureus, or MRSA, a strain of staph bacteria that does not respond to penicillin and related antibiotics. Blevins subsequently ordered the schools closed for cleaning."

That all being said, I'm still unclear what is the next step.  One could conceivably criticize the CDC for publishing this article without a broad public outreach educating the masses...

...except they probably don't know what to tell people.  We're left with a basic conundrum in this episode:

• we got this drug resistant bacteria due to antibiotic overuse
• people are now scared of this bug and may demand antibiotics for any skin lesion
• they may be right - maybe we do need to treat more skin infections so we don't get more invasive diseases
• but treating more patients will invariably get us...more drug resistant bacteria, which may not respond to the antibiotics we have now.

Where are Julie Gerberding or Anthony Fauci to help us out?