Moving Forward

As the semester nears its end I am realizing how this course came full circle. It all comes back to the fact that American health care is inherently bad. This happens in many cases where criticism overpowers progress being made. This course has brought to light every negative aspect and stage of our healthcare system. This started from the misguidedness of early homeopaths to the profit-hungry insurers and the limitations of government assistance in Medicare and Medicaid. This is compounded by all of the tables and figures showing how awful our system is from costs, medicalization and rankings compared to other countries. In many ways, I’ve found that this system is truly broken. For example we are one of only two countries, along with New Zealand, that still allows direct to consumer advertising for pharmaceuticals. Also in a general view the fact that not everyone has a basic coverage of healthcare is clearly a problem. With that being said, if there is one thing that makes this country great it is choice. While it may not even be an idea for some, people in the US have the choice to seek out alternative therapies or plastic surgeries. They also had the option to be covered in a very limited way if they think they will be healthy, or extensively if they can afford it. There is of course a fine line between what is right for this country and what keeps our freedoms available. The discussion of how to walk this line is always a great point of discussion and must remain in discussion for years to come. It is what made this course so interesting and relevant in today’s society. The reminders of how bad our health care system has been are important but we must use this information now to move forward and make it better.

More patients dying at home, progress?

While reading the New York Times article, Fighting to Honor a Father’s Last Wish: To Die at Home, it seemed like this situation where people are put in homes against their wishes and just to the satisfaction of the nursing homes is a widespread problem. What I thought was interesting was that the percent of people dying at home had actually increased from 2000 to 2009. Unfortunately they did not include more recent data, but why would this happen? It is clear this is what patients have been asking for, for many years through living wills and conversations with families but is that why this changed? Are families starting to have that conversation earlier or is it the physicians that are taking charge and bringing everyone together to make a decision? Also does this mean that we are starting to solve this problem of going against peoples wishes? There still is a huge gap from the 35% that die at home to the ~60% that wish to die at home, but it is interesting to see some progress.

End of life care: death or bankruptcy?

It makes sense that most of what we look at in this class is through the lens of patients with lower SES or wealth, but in the Atlantic article, Long Live and Pay for it, it’s not. We see a man who’s parents were able to pay for five years, at $100,000 per year, for his mother at a continuum of care facility. For many, this is funded by medicare but as usual there is a huge gap between who can pay for care or insurance and who is covered by medicare. The question is what would a better system look like for end of life care? If even the wealthy are affected like in this case and had to live with costs over what they “should” be able to finance, how can someone with a lower income survive this? When any group is looking for social health coverage it seems it always comes down to what is the baseline of care that everyone should receive? Bring this too high and the government goes further in debt, bring this too low and millions will be left without sufficient coverage.

To Curb Rising Costs, Experts Call For Ban on Prescription Drug Ads

To Curb Rising Costs, Experts Call For Ban on Prescription Drug Ads                                                                                

The AMA recently voted in favor of a ban on prescription drug ads directly to consumers. They want to ban the ads on TV and magazines which directly impact the patient’s decisions.

It is interesting to think about why pharmaceuticals are advertised to patients in the first place. One of the main problems is that the average patient isn’t going to have an extensive knowledge of all of the different options for them out there for a given condition. That is why they go to their doctor. Their doctor would tell them whether prescription drugs are the right option and if they are, which one is right for them based on other conditions and factors they have. It has been shown that patients who ask their doctor about a prescription drug they have seen on TV are much more likely to be prescribed a drug rather than be given advice about their condition like a diet or lifestyle change. Also, many ads are directed at patients with mental conditions. If a patient with bipolar disorder or PTSD is told by an ad that they may need a certain prescription they may be so convinced that their doctor will have no choice but to prescribe the drug.

New Zealand is the only other country that allows direct-to-consumer ads for pharmaceuticals, but they have strict regulations about the information they must include in their ads. This is intriguing because it is yet another time where our healthcare system falls behind as we have seen in class, but this has to be taken with a grain of salt because of the different systems that other countries have. In England, with the National Health Service, everyone is guaranteed healthcare so a patient may be more likely to go to their doctor and ask for advice for a medication than researching blindly on their own.

On the other hand, how would physicians decide which drug to prescribe? There could possibly be a system where every drug made is generic. This would show exactly what the drug does and there would be no question of which drug to choose, just whether or not to prescribe a drug. While this may seem ideal, it would ruin a huge system of pharmaceutical companies that have nearly endless power in lobbying congress. Essentially, this would not work because of the capitalistic system we have set in place. Something I think could work would be to replace the direct to consumer advertising with an amplified system directed at physicians and hospitals. This would probably be a similarly confusing system and may lead to problems with prescribing less effective drugs due to physicians persuaded by ads or by hospitals trying to cut corners, but at that point it could be another battle to remove pharmaceutical ads entirely. Deciding whether that would be the right decision seems to be the next battle after this ban has been passed.



What should the future hospital in the US look like?

After reading The Rise of The Modern Hospital and watching the video in discussion about medical tourism in Bumrungrad International Hospital I’ve been wondering what the hospital of the future should look like. There are many hospitals like Bumrungrad which are capitalizing on the market of medical tourism and providing excellent service at what is essentially a five star hotel for a much lower price than a US hospital stay. Should hospitals in the US be capitalizing on this market? I want to say that they should not. There have been shifts for many hospitals in the US to be more like nice hotels but I think something like medical tourism would not work. I think it would be easier to fix the system we have rather than trying to get foreigners to come here for treatment. The only reason I could see is that they would bring in extra profit that could be used to improve our present system.

How do we fix any healthcare issues in the US when the most basic issues are still debated?

After attending Dr. Paul Farmer’s lecture today I felt that change in healthcare truly is possible. He told stories of how his organization, Partners in Health, taking advantage of the governments support, brought about a great change in Rwanda’s health care effectively setting them on a path of healing. He said that what got him into the industry was his interest in human and civil rights issues but he believes he’s gone onto more important things. The problem I’m seeing is that here in the US, the racism and human rights issues are still a huge issue and center for debate. It has been brought up in the readings the past few days, especially in “A Silent Curriculum”. The problem I believe is the fact that these issues such as public healthcare as a right are such polarizing ideas simply due to the political party system. Dr. Farmer skipped over the human rights issues because he thinks it is so clear that universal healthcare is the right decision that it doesn’t even deserve a debate. How can we fix any healthcare issue in this country while such basic issues are still undecided and take so long to move one way or the other?

No alcohol during pregnancies – ever – pleads pediatricians

So many headlines in the news today scream out what you may see as obvious. Don’t drink alcohol during your pregnancy. Seems pretty simple. Of course it is difficult for many alcoholic women, but for the educated women they should be able to abstain from drinking for 9 months right? Somehow that is not the case. This article is essentially a collection of quotes from studies, doctors and other health professionals speaking out against alcohol consumption during pregnancies. It is often a topic of discussion what level of consumption you can get away with without complications, but many organizations are begging people to err on the side of caution and refrain from drinking. Most recently, the American Academy of Pediatricians stated that no alcohol should be consumed during pregnancies.

One of the sources commonly referenced in the article was a 2012 study by the Center for Disease Control and Prevention. They used a figure made from the CDC’s data comparing education levels and drinking during pregnancies. What is quite shocking is that it shows a clear trend of more drinking with higher education levels among pregnant women. Those with college degrees were more likely than those with some college education who were then more likely than those with no college education to drink at all or to binge drink. This made no sense to me. How can women who are more educated drink more during their pregnancies than their less educated counterparts? They have clearly heard of studies like this and the general idea that this could be detrimental to their babies and should be more educated on these consequences.

Following up on the CDC study, they showed that women who were drinking in the preconception period were more likely to continue than those who drank less frequently. This could be why there is a higher prevalence of drinking during pregnancies among the college educated. Many students start drinking during college and these studies show they have trouble stopping. This points to the binge drinking culture present in many colleges. It is, of course, difficult to stop doing something that you enjoy once you start. This is especially true in this case because alcohol is not only a pleasure, but often an addiction or a dependence. That is why something needs to be done to fix this absurd culture and prevent many people who would not normally start drinking at unhealthy and unstoppable levels from starting.

How could mostly genetic diseases have a higher occurance with lower socioeconomic class?

At the beginning of Chapter 3, it was stated that nearly all diseases have a higher occurances within lower social classes. For most cases this made sense to me. The lower the class, the more dangerous occupations they hold and the more unhealthy food they eat. But then, what about conditions that are mostly genetic? With some, like diabetes or heart disease they might have the same genetic risk factors as a wealthy person but the conditions they live in like the access to healthy food would likely cause those risk factors to cause real conditions. For other entirely genetic diseases it seems that socioeconomic class should have no effect on occurrence rates. This would include diseases like Crohn’s disease as well as many cancers. In what ways could this be controlled by class? The only way I can think of is the cost of the care that people with these conditions need. They may be of a high class when they find out they have cancer but because of the high costs it could bring themselves and their families down to a lower class.

What will the future of US health care look like?

While much of this course so far has been learning about the downfalls of the American health care system and the successes of the systems of other countries, the readings and lecture for class today brought up some interesting topics. First of all, it showed that maybe we are possibly moving in the right direction. The Affordable Care Act has been shown to at least slightly decrease the number of people without access to health care. There are of course many flaws that we discussed such as the fact that the improvements to Medicaid were up to the state to introduce, but I think it will be very interesting moving forward to learn about the positives of our current system and how it needs to be improved in the future.

It was also interesting to learn about the convergence theory as it applies to health care. It has sounded like the single payer systems in the UK and Canada are some of the best systems, so why would they consider such a flawed and somewhat corrupt system that a market system would bring about. In the same way, the Affordable Care Act and other proposed plans in New York and Vermont may bring us closer to much of the rest of the world.

All of this makes me excited because it’s essentially why I chose to take this course. While it is fulfilling a premed requirement, I chose this one specifically because I wanted to be more informed. Most courses like biology and history teach facts that will help you on a test, but this kind of information will help me far past the tests and papers of a college course. I’ve always felt lost when it comes to anything political and I’ve noticed the discussions about politics have become more and more about health care systems and reform in the US. After just the beginning of this class I already feel more prepared and educated for the various topics in the elections and debates.

Surge in statin use among very elderly raises doubts

This article, published in USA Today, found a trend in which many doctors are starting to prescribe elderly patients more preventative medicines. It focuses on one type of drug, statins, commonly known by brands such as Lipitor and Crestor. Statins are most often used to lower cholesterol levels in patients with high cholesterol levels. By lowering cholesterol, they in turn reduce the risks of heart attacks and strokes. According to the article, they have been clinically proven only to reduce risk in patients who have already had one of these conditions. Interestingly enough, the article points out that even in elderly patients without a history of these conditions there has been a four times increase in prescriptions since 1999.

This trend, along with other trends we have discussed in class brings up the idea of overtreatment. Although many view a push toward preventative medicine as a positive, it is clear there needs to be a balance. Preventative medicine is looked at as an investment in your future. Take this pill now so you won’t need that surgery later. This works for many cases but they can come with immediate consequences. With statins these consequences are side effects and overall cost. Although not common, the side effects can include muscle pain and the onset of diabetes. The article states that statins would cost $30,000 over a lifetime so for the age range in question that number could be closer to $5,000.

While $5,000 isn’t that much to pay to escape a potential heart attack and the surgery that would follow, the risk of diabetes might be, especially when many of these patients are not at that high of risk for these complications.

This article also brings up the topic of overprescribing and over treating. While somewhat different from over testing, when the prescription rates increase four times with no scientific evidence backing it, it is clear there is a fundamental problem with how drugs like this are prescribed. Unfortunately it is difficult to obtain information and perform studies with the elderly with preventative medicine because many it is difficult to predict the time they would be able to put into the trials and many also have other conditions and medications which may interact with the medication being tested.

Possibly the most interesting part of the article is the last line: “We just don’t know”.