Healthy Policy

Medical bankruptcy

A new report was released today found that only 17%, not 46%, of bankruptcies are caused by medical bills.

What's the deal?  Is this just another case of the CW being very wrong?

It appears that the discrepancy comes from quibbling over the source behind the "cause".  The first study, done by Harvard researchers, surveyed over 1,700 people asking them if "medical bills or illness caused their bankruptcy".

Unfortunately, they didn't make much of a distinction between whether illness made them lose money or whether it was the bills themselves.  The new research flushed these groups out.

"It is insufficient to show that medical problems are associated with bankruptcy," Dranove and Millenson write, adding, "one must determine whether, and to what extent, medical spending causes bankruptcies." Dranove and Millenson note that for the 17% whose bankruptcy could be tied to medical expenditure, it could not be determined whether medical costs were the primary cause of those bankruptcies.

They're right; it does matter if the actual bills were the direct cause of bankruptcy.  Even so, no one should be in a position that medical bills (an actual necessity unlike a bigger house or more expensive car) cause their bankruptcy.  Especially 17% of  bankruptcies. 

Personal Anecdote Time

Re: Dr. Andy's post about compulsory vaccination, I have a couple anecdotes.

When I spent a summer in DC I had the opportunity to attend a congressional hearing on Hormone Replacement Therapy.  At one point the committee chairman went on a diatribe about vaccines and autism, and how his grandson is autistic and clearly it's the vaccine's fault.  Then he said asked the chairwoman of the heart, lung, and blood institute why the NIH wasn't doing anything about this (gee -- I don't know, because it's the FDA's jurisdiction??).  Keep in mind this has nothing to do with Hormone Replacement Therapy, which is for menopausal women.

Next in Kate's special anecdote file is the girl who got measles in one of my classes at Santa Cruz.  Now, being Santa Cruz and all, this wasn't too terribly surprising (not because there's lots of measles going around, but because there's a lot of ultra-natural people).  But a 20 year-old got measles!  It's ridiculous.

The main issue I have with "conscientious objections" to immunization is the person who it really affects isn't choosing at all.  They could get something terrible like, say, measles (or heaven forbid, Hepatitis B), down the road because of their parent's scientifically unfounded beliefs. 

Fortunately we're fine as long as the vast majority are vaccinated.  Who knows where my classmate got measles from, but she didn't spread it to anyone else. 

Grand Rounds volume whatever

The latest Grand Rounds is up at A Chance to Cut is a Chance to Cure (hmm...think the host is a surgeon?). 

Pad your resume!

A reader pointed me to this unbelievably comprehensive list of health policy/health care internships and fellowships compiled by Kaiser.  So if you're looking for an enriching experience (or perhaps some resume padding) this is the place to go.

Doctors, start your tablets

When I talk with people (even health policy people) about ways to implement more technology into health care, like doctors using computers during appointments, I get some interesting answers.  Like computing while seeing patients will destroy the doctor-patient relationship.  This answer is quite puzzling, as the doctor-patient relationship is pretty mutilated already, and the benefits of direct computing by physicians (cost, time, efficiency, and most important: reduction of error), seem to outweigh the discomfort of your doctor occasionally typing things in.

But (via the Health Business Blog), Microsoft is introducing a new product that can quiet this debate with one fell swoop:

The Microsoft Origami Project seems to be a nice little tablet-style PC along the lines of the Motion Computing LS800 that I have described before. It's the kind of hardware that makes electronic medical records, e-prescribing and decision support tools all the more practical for physicians by making it possible to carry a full-featured device in a lab coat pocket.

And I'd add, without a big screen that apparently perverts the essential nature of physician care.

The VA tackles obesity and diabetes

The Veterans Affairs health system is rolling out a new program to combat obesity and diabetes among veterans:

As part of the new program, VA doctors will give out "prescriptions for health" to patients after measuring their body mass index, a measure of body fat. The prescriptions will list exercises and nutritional information that match patients' health needs.

Their excellent HIT infrastructure will provide easy assistance in implementing this program.  We're desperately in need of solid public health and prevention programs; success here could indicate a model for other practitioners to adopt. 

Further, VA members actually have a problem with obesity and diabetes.  70% are obese, compared to 31% of the general population.  An astounding 20% have diabetes, compared with 7% of non-vets.  So there's real room for improvement. 

Let Them Eat Mangoes

This is just infuriating.

How to entertain yourself while being an invalid

This is a little out of the blue, and I'm not quite done with my convalesence yet, but you might be just starting your surgery/etc, so here goes:

How to entertain yourself when it's difficult to leave your house:

1. Start a blog.  Convince yourself that people are reading it, so you must write something in it everyday.  By a certain time (like 10 am).  That will give you a sense of accomplishment and reason to get up before one in the afternoon.  Otherwise the days become long and aimless (surprisingly so since you're sleeping in the afternoon).

2.  Find some favorite shows.  I've been watching Project Runway -- there's a new episode every week and I honestly look forward to it.

3.  Avoid message boards unless you have a major dilemma.  A lot of the people on message boards have serious complications and they will inevitably scare you to death.  You don't need to be scared like that (bad for the heart) -- continue on in ignorant bliss.

4.  Fiction, fiction, fiction.  Non-fiction is great and all, but if you only to make out to read non-fiction, you won't finish anything.  So far I've read: Jonathan Strange and Mr Norrell (Susanna Clarke), White Teeth (Zadie Smith), A Heart Breaking Work of Staggering Genuis (David Eggers), The History of Love (Nicole Krauss), and I just started The Red Tent.  All fabulous books.

5.  Don't watch too many sports with super muscled people running around.   The Olympics almost made me throw off my crutches watching all those ridiculously active atheletes.  Remind yourself that the Olympic mogul skier will probably be in your position down the road anyways.  And who really wants their thighs to be as big as Apollo Ono?

6.  Try and make little traditions or appointments.  Again, this helps pass the time and keeps you from feeling like you're stuck in purgatory.  Make a coffee appointment with a friend every Thursday, or go see a movie every Tuesday.

7.  Always be thankful, but don't feel bad about needing/asking for help.  Don't be stubborn.  Don't wear yourself out doing things by yourself that others can help you with.*

Hope that helps someone.

*my bad

Hagel's health commission

From the News Bin:

Sen. Chuck Hagel (R-Neb.) has formed a commission of health care experts to develop health care reform recommendations for federal legislation, the Omaha World-Herald reports. The commission comprises 10 members who will examine health care access and quality, cost control, the roles of medical science and technology to improve care, and the effect that baby boomers will have on future costs, according to the World-Herald (Thompson, Omaha World-Herald, 2/23). Part of the commission's mandate is identifying "more effective financing vehicles for American health care than current public and private plans." Hagel said that the goal will be to ensure sustainable health care for all families.

Smart move.  Methinks someone is getting ready for '08.

Frustrations

I think the thing that frustrates me the most, after 10 and half weeks on crutches, is that I can't make peace with the fact that it takes me a lot longer to do things. 

Today I'm going to attempt cleaning my room.  Instead of being leisurely, taking my time to slowly crutch around while trying to balance things in one of my hands, I will hop like a madwoman all over my room.  When you hop on one leg, you get a fair amount of momentum going, so I'm sure these hops will be tempered by running into/collapsing onto my bed.  I will lay there staring at the ceiling for a minute, cursing my bum leg, then recommence the hopping.

It's quite a spectacle really.

Dr. Walker

Graham is a med student in California.  He's from my hometown and  I got to meet him last December.  He was a warm, intelligent, great guy, and I know he's going to be an incredible doctor. 

That's why you have to read this absolutely beautiful post about his patient.

Wal-Mart and health insurance

Ezra has a great post on the logic of Walmart-directed outrage.  Responding to this:

Just out of curiousity, why should taxpayers be outraged? This is after all, precisely what the Democratic party has been arguing for for decades. For a half-century, Democrats have been arguing that what America really needs is a universal health-care system, funded by taxes. Indeed, the only reason why Wal-Mart employees are eligible for Medicaid in the first place is because Democrats made a push to amend Medicaid so that the working poor could get Medicaid benefits, even though they are employed.

So, it's a little silly to be complaining that Wal-Mart employees are using Medicaid benefits when the goal of the Democratic Party is ensure that everyone gets taxpayer-funded benefits.

Ezra writes:

Yep. In fact, it's probably a helluva lot more efficient for the government to be picking up the tab. What taxpayers should be outraged by is that Wal-Mart isn't following their ethos to its logical conclusion and loudly advocating for a universal health care system. They should be angry at the hypocrisy, not the usage of federal/state health programs.

Bingo.  What's bad here is that people can work full time and still be unable to afford health insurance.  It's not that Wal-Mart isn't spending enough on health insurance; they don't spend enough on wages.  Higher wages, more than anything, would make a huge difference.  Piddling over whether Wal-Mart spends 7% or 9% on health insurance is pointless.

Washington's Weird Bill

The Washington Senate just passed a hodge-podge medical malpractice reform bill unlikely to make a difference.

Breaking down the main provisions:

• Changes that would prevent apologies to patients from health care providers from being used in court, as well as a requirement that lawyers would have to file certificates of merit when filing suit against health care professionals

Y'know, it's really fun to play this game, but unmerited lawsuits pretty much never make it to court.  It's exceedingly difficult to sue, and lawyers have no incentive to go after cases with a high risk of failure.  This change is purely symbolic.

• the bill would place a $1 million cap on non-economic damage awards in malpractice cases that go to arbitration instead of trial

I'm trying to find the stat, but I imagine there aren't many arbitrations that involve over $1 million for non-economic damages, so it's unclear how much this would do.

• The malpractice bill also would enable the insurance commissioner to reject increases in doctors' insurance premiums and collect data on malpractice payouts for analysis

This just isn't the government's place.  Why?  Because the "data analysis" will end up in a vault (or hard-drive) somewhere and is unlikely to be used for anything.

• Members of the public would be added to the doctor disciplinary board

This one is the strangest of all -- what do they mean by "members of the public"?  Is it John Q. Patient or someone with actual knowledge about medical practice and licensure? 

There's no caps on damages or efforts to make it more difficult to sue, but this amalgam of ineffective measures is a sorry excuse for reform.  Mandatory reporting of injury, initiatives to set up more arbitration, and stricter punishment for doctors (i.e. license revocation) would be much sounder ways to proceed.

Update:  Reader Public Health Press points out the more pernicious aspects of the certificate of merit: "Requiring a certificate of merit is a real change, but the devil is in the details (I don't have the bill in front of me, but that won't stop me from posting my thoughts!). Illinois requires such certificates, and recently made changes to their process. Generally, certificates are filed by the plaintiff's attorney with an attached Affidavit of Merit by a licensed medical practitioner, who must review the record and state there is a meritorious claim. That, in and of itself, is an additional administrative hurdle and cost incurred by the attorney and the patient/victim up front, and the burden goes up depending on the qualifications required of the expert (for example, do they have to be in the same or a similar specialty, or can it be just any physician with some working knowledge of the area in question?). But here's the way they can make a big difference in the number of suits filed: if the affidavit of merit requires details about the reviewing physician be disclosed (e .g., physician's names, addresses, etc.), it can create a tremendous amount of peer pressure to prevent physicians from signing on to these cases, and therefore make it significantly more difficult to get over the hurdles needed to file the claim."

Friday Fun Resources

Via Matt Holt, a Chicago couple has started a non-profit tee-shirt biz for patients with serious or chronic illness to help them feel the lighter side.  They feature shirts like: "Death: Been there, done that", "Chicks dig scars," and "Warning: High Voltage (defibrillator)".

My personal favorite is, "Think I look bad? You should have seen the other guy," because I like to mess with people when I go out on my crutches and tell them I was in a knife fight (punchline: I might have a brace, but the other guy has no leg).

It's a great project, so pass it on to friends/family who would enjoy.

Health Wonk Review

Our wonky response to Grand Rounds was born today.  Go check out Joe Paduda with the seminal round.

New webMD records

From the Great Ideas in Technology Bin:      

The New York Times on Thursday examined how WebMD Health, "one of the most-visited medical information sites on the Internet," hopes to "tap into the growing corporate trend of having employees pay more ... of their own health costs" by "helping people enrolled in employer health plans compile personal health information online." WebMD has signed multiyear licensing contracts with health insurers Aetna, Cigna and WellPoint and almost three dozen large U.S. employers -- such as Bank of America, Cisco Systems, Dell Computer, IBM, Pfizer and Shell Oil -- to operate private-access Web sites that allow employees to track their medical records, as well as find information about diseases and compare cost and quality ratings for physicians and hospitals.

I would love to participate in this program, if only because I'm so tired of filling out 5 million forms every time I go to the doctor.  Continuing the cycle of inefficiency, the nurse asks me every single time what medications I'm taking (especially because I take more than one). 

But I also get very curious about what they write down about me in my medical record.   Don't you always want to grab your record when the doctor leaves the room for a second and thumb through it?  Now you can. 

The Looming Cost Crisis

The doomsday predictions have arrived:

U.S. health care spending will increase by an average of 7.2% annually until 2015, when spending will reach $4 trillion and account for 20% of the gross domestic product, according to a report released on Tuesday by the National Health Statistics Group at CMS

Health spending the previous four years increased at rates much higher than 7.2%, and most of the recent decrease was due to a lower utilization of prescriptions.  With the Medicare drug benefit now implemented, much of those savings will be erased.  It's also unclear exactly how much the benefit will cost, so those predictions are volatile.   As every sector of health care spending almost doubles, premiums will sky rocket.  Unless substantial reform is enacted, expect the number of uninsured to sky rocket as well. 

Regardless, 2015 is now only nine years away.  And nothing we have right now is going to slow spending enough in nine years time.  Paul Ginsberg thinks there's another reason that spending will increase more than 7.5% a year:

Ginsburg also said that the report was "optimistic" because the authors are "only following current laws on the books, which means they assume there will be continued physician payment cuts in Medicare," adding, "But people don't expect that to happen".

Bush refused to push through with Medicare fee cuts this year.  It really depends on the political climate of the next presidency on whether or not those fee cuts will proceed.  They're substantial -- 26% over 6 years.  In the place of reform, legislators might go ahead and push through, but it will be an uphill battle.  Doctors will take on a massive PR campaign claiming they won't be able to see any new Medicare patients.  With so many baby boomers on the verge of retirement, you can be sure that won't sit well.

The percentage of growth might be higher or lower than 7.5%, but doomsday is coming.  Employer and employee alike will feel the financial pain as industry attempts to adjust to these costs.  It's an unprecedented amount of growth, and we can't underestimate its effects on the economy. 

Medicare leads the way for weight-loss surgery

Via Kaiser, Medicare has agreed to pay for three types of weight loss surgeries:

Three of the most commonly performed bariatric procedures -- Roux-en-Y gastric bypass, gastric banding and biliopancreatic diversion with a duodenal switch -- will be covered as long as beneficiaries obtain the services at centers that have been certified as well qualified by the American College of Surgeons or the American Society for Bariatric Surgery, the Post reports (Stein, Washington Post, 2/22). To qualify for the surgeries, beneficiaries must have a body mass index of more than 35 and one or more weight-related health problems, including diabetes, heart disease or sleep apnea, according to CMS. In addition, beneficiaries must have tried other treatments unsuccessfully, USA Today reports. CMS officials said they do not know how the new coverage will affect costs, though they believe the costs will be significantly less than what Medicare spends on coronary bypass or heart defibrillators.

Far from the UK's recent bias towards those with obesity, Medicare is going where many private insurers refuse to.  It's good to see they've added some qualifiers like trying other treatments and suffering at least one obesity-related disease, although I wonder how strictly those guidelines will be adhered to.  Unfortunately, when you get over 65, it's fairly difficult to lose weight through exercise and diet has to pick up much of the slack, so surgical options might be more appropriate for this age group.

I'm quite surprised that weight loss surgeries are only  $20,000 -40,000, as my own minor leg surgery was $23,000.  One frustrating insurance practice is their inability to recognize that denying treatment for current illness will end up costing them a lot more down the road.  Maybe they think they can get away with it in our shifting employment market because there's a fairly good chance that a claimant will be on another plan down the road when they incur these costs.  But with Medicare, you can be fairly sure an enrollee will stay a Medicare enrollee, so the trade-off of paying for surgery versus not paying and later being responsible for cardiac care is easier to predict. 

I'm also curious to know how many people over 65 would qualify for this.  It seems most people needing this kind of surgery are between 20 -- 40, and can recognize the long-term impact of such a drastic procedure.

One more thing -- how much higher is the death rate over age 65 for these procedures?  That's worth looking into, because it's major surgery with a fairly high risk of death, and being over 65 surely increases that risk.  It probably depends on the patient's BMI.

South Africa and the HSA Experiment

HSA's are a relatively new idea in the U.S., so it may come as a surprise that another industrialized nation has several years experience with the accounts.  But they have enjoyed good market penetration in South Africa for long enough to examine some of the results, and yesterday the Wall Street Journal took a look. The majority of the population has publicly funded insurance, mostly due to ability to pay.  About 15% have private insurance, most of which are HSA-style plans. Discovery Health, the key HSA provider, has had extensive success with HSA plans and seen its stock price double in a year.

As President Bush proposes changes to make HSA's easier to purchase, it's important to look at other nation's experience with them.  And South Africa serves as a troublesome teacher.

The introduction HSAs had some unexpected effects which have wreaked havoc on the country's insurance system.  For one, plans are keeping costs low by competing over the healthiest customers.  David Adler of the New Republic explored the effect of HSAs in South Africa and wrote:

The South African story, then, is a move from a noncompetitive insurance environment to a competitive one, but the competition wasn't by hospitals to provide the best or cheapest care, but rather among insurers to get the healthiest patients. Consumer-driven plans are central to this process, because they are ideal for "risk-selecting" the young and fit, who have flocked to the new plans. Not in need of expensive medical care, the healthy could watch their account balances grow, leaving the truly sick behind in traditional plans.

Fortunately, South Africa is stepping in to keep insurance companies from this practice.  As the Wall Street Journal noted,

Starting in about a year, companies whose insured populations are disproportionately filled with the young and healthy will have to pay a penalty.

The strategy has gotten so out of hand that South Africa, a nation that has in the past accepted very little insurance regulation, is intervening.

Unfortunately, it gets worse.  Not only has have the plans stratified the sick versus the elderly, they haven't contained costs at all.  In fact, costs have risen.

Between 1996 and 2001, the cost of specialty care increased 43 percent, and the cost of hospital care rose 65 percent. This represents a marked increase from the inflation rates for the five years prior. There have also been substantial increases in plans' administrative costs (which include profits). 

So there you have it.  The two things that U.S. policy makers fear (decimation of insurance and inability to restrain costs) have already played out in South Africa.  HSA backers make a lot of promises, but there's little evidence that all of their lofty goals will play out in the actual U.S. insurance market.  South Africa's experience alone is reason to be very skeptical.

why I'm a bad lady who didn't write anything yet today

Hi folks.

I'm sorry I'm majorly slacking today.  I couldn't sleep last night, so I got up a bit later than usual, then I had a conference call with an unnamed Governor, followed by completing an application for a job at Kaiser!

So it's been a busy afternoon. All good stuff except for the not being able to sleep thing.  Regular posting will now resume.

La Grand Rounds

is up at Dr. Andy.  Take a peek.

Public vs. Private

If you read this post, you'd probably think there are only two ways of doing health care in the world: public and private.  So when George Reisman goes on a little fear-mongering like this:

And there you have it. Socialized medicine destroys the quality of medical care and dare not allow the competition of private medical care. To prevent that competition, it must prohibit private medical care and establish a legal monopoly on medical care.

I'd ask him to take a look at France.

There's many ways of organizing health care delivery, and I agree with Reisman that flat-out prohibiting private care is a bad thing.  That's why the French system is the model (not Canada) I'd use for the U.S.

Because France is a public-private hybrid, it combines the best of both worlds.  The public component establishes a baseline of quality and care, along with the efficiency of single payer.  The chief problem with U.S. care is access, and that needs to be addressed first.  Then the private component allows patients more access elective and experimental treatments and shorter waiting times. 

Sounds great in theory right?  How about in practice:

The health care system is mainly under state control. The state plans out hospitals, the allocation of specialized equipment, etc. Some of this is done at the regional level, a trend which seems to be increasing. The hospitals offer about 8.4 beds per 1,000 people (America, btw, offers 3.6. Ouch.) The public sector provides 65% of the beds, private hospitals -- which operate on a fee-for-service basis -- make up the rest, and primarily concentrate on surgeries. French citizens choose which one to go to and get the same reimbursement at either. How's that for choice? Not good enough? The French also get to choose their physicians, their physicians get to choose where they practice, and there's patient-client confidentiality.

That's hardly the doomsday scenario Reisman would have us believing.  Sounds heavenly to me.

The key thing to understand here is that it's not an either/or situation.  For Americans, who tend to be distrustful of government, a hybrid system is much more palatable.  It's funny that de Tocqueville's people beat us to it. 

More Enrollment Problems

As both Cindy and I have discussed previously, there's reason for concern about Medicare Part D's long term viability if it fails to meet enrollment goals. That's because of adverse selection, which in normal speak means the tendency for sick people to sign up for insurance over healthy people (because they anticipate they'll need it more).  But any viable insurance pool requires many healthy people to off-set the costs of the sick.  With Medicare Part D, seniors who don't take any prescriptions, or only a couple inexpensive ones, won't deem their monthly premium, co-pays, and initial $250 deductible worth paying for.

So far that's been the case.  But low-income seniors who don't qualify for Medicaid can still participate in the drug benefit for no premiums or deductibles and co-pays of $5. And as the Washington Post reported today, even that proposal has a snag:

A $400 million campaign by the Bush administration to enroll low-income seniors in prescription drug coverage that would cost them just a few dollars per prescription has signed up 1.4 million people, a fraction of the 8 million eligible for the new coverage.

   

At this rate, by some calculations, the government is on track to spend about $250 for each person it enrolls, and even then it would have only 2 million poor senior citizens taking advantage of what is perhaps the most generous government benefit available today.

The problem they're running into, of course, is that it's complicated to sign up.  As I often experienced with my work at the Venice Family Clinic in Los Angeles, the largest free clinic in the nation, it can be exceedingly difficult to get patients to sign up for assistance.  With Medicare Part D, these seniors first have to choose from among dozens of drug plans, then they have to pass a series of means tests to get the discounted coverage.

The key is a streamlined process. Anyone who's worked with low-income Americans can tell you that the best way to get people to participate is if you can finish the application in one visit (it's hard to get people to come back again).  Social workers need to memorize the facets of available drug plans for low-income seniors and present them with 3 or 4 options (rather than 10 or 12).  Means testing isn't as easy, which is why it's crucial to use trusted individuals when dealing with sensitive information.

Remarkably, Medicare outlined a program that would have worked much more smoothly, but inexplicably scrapped it for mass-outreach methods:

The council provided a report to Social Security last spring outlining a recruitment strategy that Firman said would have enrolled millions more seniors and cost about $100 per person. They key involves using "trusted intermediaries," such as volunteers at community centers, to work individually with each client, he said. Mass mailings, group meetings and advertising are insufficient when dealing with a hard-to-reach population and an application that involves supplying both income and asset data, Firman said.

Sometimes, it's hard to believe the Administration isn't purposefully trying to make Part D fail.  They're certainly doing a good job accidentally doing so.   

 

Olympics

I, for one, am having a fabulous time watching the Olympics.  Never in my life have I wanted to go to  the gym more and pump some major iron.  I think the whole frustration with crutches thing is exacerbated by watching all these health people running around using their enormous thigh muscles. 

But my favorite is watching all the weird winter sports that have somehow survived.  Curling -- what the hell?  I watch it because it's so strange!  Skeleton scares the crap out of me -- I wonder how many people have died or sustained spinal cord injuries from hurling themselves down a track at 70 miles an hour head first.

The only thing I don't like is Mr. Bowtie Tucker Carlson being MSNBC's day host.  He annoys me to no end.  Down with Bowtie!

Ladies and Gentlemen

Always pay your prostitutes.

Reminder

This is just a reminder to everyone that I'm also posting at TPM Cafe, so if you noticed I haven't been writing quite as much here, it's because a lot of my work is going there!

Plus there's fantastic health policy experts joining me, so you should read them too.

Regulating herbal therapies

I'm going to expose my lack of medical training here, but re: this new study:

A large, seven-year study of healthy women over 50 found no broad benefit from calcium and vitamin D supplements in preventing broken bones, despite widespread endorsement by doctors for the supplements.

The study, whose results are being reported today, also found no evidence that the supplements prevented colorectal cancer, and it found an increased risk of kidney stones.

Isn't there evidence that women can only increase their calcium levels before 40?  And after that calcium levels fall drastically, and taking supplements can't do anything for it?

I'm strongly in favor of regulating supplements and herbal products.  Consumers spend billions of dollars a year on products whose therapeutic evidence is usually weak at best.  It's great that NCCAM was created, but  its research has proven less than encouraging so far: St. Johns Wort has no value in moderate or major depression, Echinacea doesn't do anything for colds, and vitamin E does nothing for joints.

I went to college in Santa Cruz, CA (home of the "natural lifestyle") and natural pharmacies were everywhere.  It's not wrong that people want to do things naturally, but they deserve to know that the treatments they're paying for (many cost upwards of $100/month) have no evidence to back them up. 

How much do we charge smokers?

There's been a lot of talk about charging smoking employees more for their health insurance.  Several companies charge employees an extra $20 to $50 dollars a month for their habit.  But how do they come up with that?

Are there numbers somewhere that say smokers cost an extra $x/month on average?  Or is this an arbitrary way of estimating how much extra smokers should pay?

Difficult trade-offs

I just want to link to this post of Joe Paduda's in light of my recent post on bone stimulators.  My situation is only putting off treatment that makes patients heal faster.  Cancer drugs put off death.

I'm going to go out on a limb here and say, despite the enormous cost, if anyone in your family has ever died of cancer (as in mine) or a family friend (or even friend), which again, has happened to one of our family friends, you know months count.  They really do, especially at advanced stages of illness.  I believe that especially when you're paying for health care as a nation, these kinds of costs that can preserve some semblance of the person for a few more months are worth it, if the patient and family want it.

The bottom line isn't, and should never be, cost.  It's care.  It's mercy.  There's a big difference between unnecessary MRI's and putting off a terrible death so someone has a few more months with their loved ones.  Sure it's an enormous cost, but I believe it's worth it.

What do you think?

Conflict of interest

Roy Poses of Health Care Renewal has a great post about enacting ethics reforms between physicians and device makers:

USA Today has weighed in about stricter standards for physicians' relationships with pharmaceutical and device companies, leaning heavily (as did the New York Times previously) on the recent article in JAMA by Brennan et al.  Unlike the Times, USA Today ladeled blame about evenly on physicians and industry. And the editorial's position on which of the specific rules advocated in the JAMA article should be adopted, I must say, mirrors mine.  But, in my humble opinion, USA Today stumbled badly on the issue of enforcement. The editorial endorsed enforcement by academic medical centers, without raising any questions about whether their leadership is more ethical, or less conflicted than physicians. Furthermore, it also suggested that "managed-care groups can help enforce rules for their participating doctors."

I'm often astounded at reporters' ignorance when it comes to health policy.  I understand that it's complicated, but thinking that managed care is a panacea for ethics problems is one of the worst ideas I've heard in awhile.

In any case, readers of Health Care Renewal know that academic institutions are having plenty of their own ethics problems as well.  Take the University Medicine and Dentistry of New Jersey, which has a federal investigator, UC-Irvine which is apparently incapable of running organ/bone marrow donation programs, and Sheffield University which fired a professor for questioning methods in a pharmaceutical research study. 

What Managed Care can do, however, is refuse to cover drugs that have been clinically shown to be either less effective than older medications or no more effective.  At the National Health Policy Conference, one speaker showed a power point detailing the efficacy of various blood pressure medications and their prescription rates.  Calcium Channel Blockers, the newest group of drugs, are actually much less effective than dirt-cheap diuretics, yet still enjoy popular prescription rates.  Using this information, insurers should refuse to cover calcium channel blockers unless the physician submits an additional request for use if the patient has bad reactions.  It's really that simple. 

Problematic

Via Matt Holt

A new analysis by one of the nation's leading health economists finds that the Administration's proposals to expand tax breaks for Health Savings Accounts (HSAs) would cause a net increase in the number of uninsured Americans.

The analysis, conducted by Jonathan Gruber of M.I.T., projects that while 3.8 million previously uninsured people would gain health coverage through HSAs as a result of the President's proposals, 4.4 million people would become uninsured because their employers would respond to the new tax breaks by dropping coverage and they would not secure coverage on their own. The net effect would be to increase the number of uninsured Americans by 600,000.

"The Administration estimates that its HSA-related tax proposals would cost $156 billion over the next ten years, which would worsen the nation's fiscal problems," Robert Greenstein, the Center on Budget and Policy Priorities' executive director, noted. "Professor Gruber's study raises very serious questions about the wisdom of these proposals."

What makes a great doctor?

This is a great post by the Cheerful Oncologist on what it takes to be a great doctor.  CO says:

1. A great doctor loves the written word.

2.  A great doctor is curious.

3.  A great doctor is observant.

4.  A great doctor is a problem-solver, not an excuse-maker. 

5.  A great doctor enjoys the company of other people.

6.  A great doctor has no hidden agenda.

And finally, a great doctor possesses fortitude

As a life-long (and intensively treated) patient, I'd add two more to this list.  8. A great doctor is a great communicator and 9. A great doctor chooses a great nurse

In my mind, you can be as incurious as you like, but you have to be able to talk with your patient and their family frankly and in layman's terms.  Don't use anatomical language without explaining what it is (for example: instead of saying "there might be a tear in your meniscus" say, "there might be a tear in the cartilage in your knee, which is called the meniscus"). 

A great nurse makes all the difference in the world.  Not just for the doctor's work load, but for the patient's impression of the doctor.  I can pretty much guarantee I wouldn't have nearly as positive of an opinion of my surgeon if his nurse wasn't the best nurse I've ever met.  She makes our next appointment while we talk to the doctor.  She comes in before and after him to brief us/see if we have any questions.  She called me yesterday morning to check in and see how I was doing (I'm nine weeks out of surgery, mind you, not one).  She makes a strong impression that I'm receiving top-quality care. 

So there you go.  Don't forget to speak down on earth with the rest of us and appoint a great representative. 

Grand Rounds: V-Day Edition

Maria of Intueri has an awesome grand rounds a la Valentine's Day personals style.  Great stuff.  Go check it out.

Donut holes cost twice as much

(cross-posted from tpmcafe)

Donut hole insurance plans often seem generous because they don't require an up-front contribution to health care every time you see the doctor. Instead, you only pay past a certain point of spending.  But as a recent Health Affairs article by Meredith Rosenthal of Harvard detailed, donut hole deductibles actually end up being twice as large as standard deductibles, increasing both financial risk and out of pocket contributions by patients.

The economic theory goes like this: a standard (aka first-dollar) deductible, like those in high deductible health plans (HDHPs), affects everyone.  Let's say a plan has a $250 deductible.  Each person who spends between $1 and $250 on health care (which will be nearly everyone) will be affected by the deductible, and thus pay more, with an average amount being saved by the insurance company because of cost sharing.  In contrast, consider a donut hole deductible, from $500-$1,000.  In a donut hole plan, fewer people will pay the same average amount of the standard deductible.  That's because the number of people who will spend more than $500 (the donut hole threshold) on health care will be much smaller than the number who will spend between $1-$250 (the standard deductible plan).  In order for the insurance company to save the same amount as the standard deductible, the donut hole must be bigger to capture the same number of people.  How much bigger?  According to Rosenthal, the donut hole will need to be about twice as large to compensate.

This theory holds for the Medicare Part D, and Rosenthal estimated that if the new benefit had a standard deductible instead of a donut hole deductible, the size of the deductible could be decreased by half. 

This design means that although the insurance companies (and the government) will save the same amount of money by actuarial estimates, much greater risk is shifted to enrollees.  That's because those who have the highest costs are now facing an out of pocket payment that's twice as large as a standard deductible.

As Rosenthal notes:

Most beneficiaries will thus perceive that a doughnut-hole policy is more generous than one with a first-dollar deductible, despite the gap in risk protection. This may be the case because although employees and Medicare enrollees should theoretically prefer first-dollar deductibles, they may be more concerned about getting their "fair" share of annual benefit spending than about risk protection. They may also greatly underestimate their risk of having health care spending in the doughnut hole.

The average amount spent on health care usually determines where donut hole deductibles begin.  For Medicare, that was $2,318.  The Part D donut hole starts below this, at $2,250, so a good portion of enrollees will end up paying in the donut hole, many much more than they anticipate.   

It's unclear whether donut hole designs restrain costs either.  Patients may be less likely to restrain spending because they'll have to pay in the future instead of making those payments up-front. 

In any case, we need to think deeply about insurance plans that punish the sickest members of our society. Most people who get into high levels of spending have no control over their illness.  They didn't ask to be ill, and donut hole deductibles saddle them with an out-of-pocket payment that's twice as large because of it.  Is that the moral thing to do?

Not so small

Medicare is going to start covering some ultrasounds:

Medicare beginning next year for the first time will cover ultrasound screening for abdominal aortic aneurysms for high-risk groups of beneficiaries, the Wall Street Journal reports. Categories include those who have a history of aneurysms in their family or males who have smoked more than 100 cigarettes in their lifetimes, according to the Journal.

Considering how high smoking rates used to be, I would imagine a large percentage of male seniors have probably smoked more than 100 cigarettes in their lifetime.  They should be tested, but with that criteria, it's not exactly going to be a tiny group. 

New research on high deductible plans

A new Commonwealth Fund/EBRI report has some unsettling findings about CDHP's:

Countdown to v-day: time for chocolate!

I know what I'll be doing tomorrow...Let Dark Chocolate Be Your Valentine

In which I demonstrate the conflicts in paying for health care

I'm now 8 weeks out of surgery, and it's been pretty slow-going.  For instance:

• I'm still on crutches, and have at least 5 more weeks
• I haven't started any official physical therapy
• I can only bend my knee 70 degrees
• My bone isn't healing as quickly as it should

Now, having said all that, my pain level is very low and if you asked me to choose one word to describe my surgery it would be "inconvenient". 

Because my bone is taking longer to heal than it should, my doctor prescribed me a bone stimulating machine, which is basically a little ultrasound machine I put on my leg for 2o minutes a day.  Unfortunately, these machines cost somewhere in the neighborhood of $2,000 - $3,000.  My insurance company, very cognizant of this cost, will only approve the machine for use if it's been at least 3 months since the fracture.  That means at the time it was prescribed to me (7 weeks) I'd have to wait 5 more weeks to even begin that therapy.  This policy make sense for insurers; most bones will be healed within three months and the machines are quite expensive.  The problem is patients are left languishing on crutches, being much less productive and having a lot more pain.  For me especially, because the minute I'm healed I'm packing my car and moving to D.C., this waiting period is particularly stressful.

But I managed to dodge the bullet because of the FDA.

The FDA approved this device with the stipulation that each couple thousand dollar machine be used only once (which in part accounts  for why the machine is so costly each time to the insurance company).  I asked the device rep why that is, and she thought it had something to do with part of the device contacting the skin, although that part could be easily replaced.   Because the device can only be used by one patient, patients keep the machines when their treatment is done.

By a fantastic stroke of luck, my dad broke a bone in his foot this spring and was prescribed the device.  While he had to wait the three months to get the machine (in part due to the fact he didn't realize he had a fracture for at least a month and half), he used it with fairly positive results. 

We were able to convince the device rep to let me use my dad's machine, so now I'm on the road to recovery 5 weeks faster than otherwise.  In quality of life terms, it makes a huge difference.  But if my dad didn't have the machine, and my only recourse was to pay the $2,000 to have it, I wouldn't (and couldn't). 

These are the trade-offs we need to think about when designing insurance.  On the one hand, it's psychologically frustrating to wait three months for treatment.  On the other, I wouldn't judge this particular treatment worth $3,000 instead of postponing it 5 weeks. 

No recourse

Via Kaiser, members of the Armed Services are forbidden to sue for medical malpractice under  the Feres Doctrine.   This doctrine holds even for injury caused by gross negligence. 

Meanwhile, the House in recent decades has passed several bills to allow military personnel to pursue lawsuits regarding injuries caused by improper medical care, but the legislation has failed to win approval in the Senate. In 2002, Veterans Equal Rights Protection Advocacy submitted to a Senate committee more than 150 cases in which military personnel or their families were unable to pursue claims because of the doctrine. "All we're looking for is accountability," Barb Cragnotti, legislative coordinator for the group, said, adding, "Because of that doctrine, there is no accountability"

This is truly terrible policy.  Research shows that doctors aren't driven by defensive medicine so shielding military doctors from lawsuits is illogical at best.  What does it say about our respect for our military if we don't hold their medical practitioners accountable? 

Upgrading

CMS is upgrading the number of telephone operators to assist with Medicare Part D again, this time from 3,000 to 7,800.  That's after its previous tinkering from 150 to 4,500 (apparently they never got past 3,000).

At the National Health Policy Conference, there was a lot of praise from progressives for Mark McClellan despite his bungling of Medicare Part D's implementation.  But the absolute floundering of Medicare telephone assistance invites deep skepticism of McClellan's competence. 

It's important to add more phone operators, the real problem is that seniors still aren't sold on the benefit itself.  As 53% of seniors polled have no plans to sign up, the Adminstration needs to focus on convincing them that it's in their best interest to buy into a plan.  That's to both avoid financial problems because of unexpected drug costs, but also for the program's long-term viability.  Otherwise it's doomed to adverse selection, and we'll have to start from scratch. 

Why patch-work initiatives fail

The WSJ reported yesterday that an initiative to cover part-time workers is failing:

Although a coalition of 60 large companies last year announced the National Health Access program -- a plan to offer affordable health coverage to their part-time workers, who generally are ineligible for employer-based health benefits -- only 10 of the companies are actually participating so far...Through the effort, the employers will use their collective bargaining power to negotiate low-cost health plans for about three million uninsured part-time and temporary workers, contractors, consultants and early retirees. Employers will not subsidize the coverage. The packages offered under the program vary from allowing workers access to discounts on physician services to a high-deductible major medical insurance plan, and the Journal reports that several of the options "are essentially bundled health care services rather than insurance."

There's a couple things happening here.  Employees prefer comprehensive health plans over bundled services, so  they might not deem the latter worth paying for.  And if employees don't show much interest, employers won't invest the cost of designing tailored plans. 

There's a larger wall to climb than employee interest, which is that it's extremely costly for employers to subsidize health insurance for part-time workers.  That's partly due to the fact that health insurance isn't a part-time thing.  You theoretically need it all the time, and it's not easy to scale it back to a part-time level that's still recognizeable as insurance.  Because many employees work part-time to supplement income, devoting a big chunk of that income to health insurance can defeat the purpose of that second job.  Further, many part-time employees are covered by their spouse's insurance and don't need supplementary coverage.

Our system just isn't designed to cover the self-employed or part-time.  The cost sharing mechanisms are based on employers and their bargaining power.  And even that power doesn't go far -- huge firms weren't able to negotiate anything above bundled services for their part-timers. 

Within our current constraints, these workers not covered by their spouses will continue to struggle for care.  Tweaks aimed at the private market won't work here; it's just too inelastic.  Allowing these workers to buy into Medicare with a sliding premium scale, however, can at least affordably cover them in lieu of a better system. 

No on tort reform

My latest column is up at Campus Progress.  It's your handy guide to the case against tort reform.  Go check it out.

Pay for Performance

One of the break-out sessions at the National Health Policy Conference focused on pay for performance initiatives and ways to make them successful.   Speakers included Ron Bangasser, a physician in charge of implementing P4P changes at his medical group in Redlands, CA, R. Adams Dudley, a professor at the University of California, San Francisco, and Margaret Stanley of the Puget Sound Health Alliance.

One of the main points I took from the discussion is that slow implementation of P4P measures is essential for success.  If a hospital or medical group takes on too many measures of quality at once the whole P4P initiative is likely to fail.  It's also important to ask providers what they'd like to see measured, as this improves compliance.  At the Puget Sound Health Alliance indicators for depression and back pain were added to the list (perhaps the Pacific Northwest's clouds and rain have something to do with that?). 

Adams Dudley encouraged would-be P4Pers to use three different incentives to increase compliance: monetary rewards, reputation incentives, and work-load incentives.  Monetary rewards are obvious and can range from dinner and movie certificates to salary increases.  Reputation, especially at large institutions, can act as a powerful incentive.  If a doctor perceives that his/her reputation is being tarnished in their P4P reviews they're likely to turn things around quickly.  It's also important to show physicians that certain measures will reduce their work load (particularly with primary care docs and internists).

While we're still a long way off from a majority of docs using P4P measures, the simple act of using patient satisfaction surveys will cause a lot of change.  As one panelist pointed out, administrators can't give any more time to docs to spend with their patients; it's up to doctors to make their patients feel like five minutes is three hours or three seconds.  We can all think of that arrogant doc who has a horrid attitude towards patients but goes around proclaiming what a fabulous doctor s/he is.  Satisfaction surveys will help bring some of those egos back down to earth.

One major problem with implementation is the very infancy of pay for performance.  Without a clear compass (or evidence to reinforce the direction), administrative and political squabbling often supersede real changes. 

It was also made clear that states can lead the way in some key respects.  If states adopt a set of P4P measures, it gives organizations a place to start from, rather than "Gee, I think pay for performance is a good idea, but what should we measure?"

 

What do Americans think about health spending?

(Note: this is cross-posted from TPMcafe because your blog host is worn out from traveling on crutches)

For us health policy wonks (or those plugged into recent data about health spending), the cost of health care in the U.S. is very troubling.  Not only do we spend more than twice as much as the other OCED countries, but it eats up an enormous percent of our GDP, at 16%.  The growth in health spending is reflected in premium increases, hospital bills, and the projected growth of Medicare and Medicaid.

If only Americans saw it this way, too.

Robert Blendon, a health opinion polling expert, made an instructive presentation for would-be reformers yesterday at Academy Health's National Health Policy Conference in Washington, D.C.  According to this August 2004 poll, 78% of Americans believe we don't spend enough on health care.

That's right -- even though we spend more than twice as much as other developed nations (and 53% more than the next most expensive country, Switzerland), Americans believe it's not enough.  It's not entirely clear why they hold this belief, but surely many Americans look at the number of uninsured and conclude we just aren't paying enough to cover them. Or that their premiums are high because insurance companies and doctors are greedily pocketing too much money.

It's not that insurance companies are greedy; it's that in our fractured care delivery system, they're very inefficient.  Most estimates place private administrative costs at 15-30%, whereas Medicare hovers around 2%. It's not that doctors are greedy either; it's that they duplicate care and continue to use expensive treatments that are no more effective than older ones.

Covering the uninsured isn't going to cause costs to go through the roof either.  A 2003 article in Health Affairs estimated that covering the uninsured would add less than one percentage point to health's share of GDP.   

These stats are all well and good, but policy makers need to connect with Americans on an emotional level.  Like: Do you worry that expensive health care is causing/will cause your employer to cut back on the number of employees? When you stayed in the hospital, did you have to repeat yourself to a lot of people?  Did you know what every test you got was for? It's essential to make these connections -- that the growth in health spending (which is in every part of health care, not just for baby-boomers and retirees), affects your job, your family, and your security.

We have a long way to go to convince the public that the way we do health care in this country is wasteful.  The first is helping them connect the dots between GM and other companies whose health costs are drowning them, and the fact that we spend too much on health care, not too little.  It's too much money not because we should treat people less, but because we pay for it in an inefficient way, we duplicate care, and we don't cover everyone we can.

National Health Policy Conference

I'm attending Academy Health's National Health Policy Conference in Washington D.C. this week.

I'll fill you all in on the happenings later this week, but I want to apologize for my non-existent posting in the mean-time.

If you're attending the conference, I'm the girl on the crutches.  Come introduce yourself!

Paradigm Shift

The Wall Street Journal yesterday featured an editorial on Harvard Business School professor Michael Porter:

Porter last week at the World Economic Forum in Davos, Switzerland, previewed "Redefining Health Care" -- a book scheduled for release in May that he co-wrote with University of Virginia professor Elizabeth Olmsted Teisberg -- Murray writes, adding, "Too bad President Bush and his advisers weren't there." According to Murray, Porter, like Bush, "believes competition can solve much of what ails the health care industry," but Porter believes that "the president is making a big mistake by focusing mostly on cost." Porter believes that the "real problem in health care ... is a lack of good information on quality and outcomes" and that, "without that information, any effort to drive down costs through competition will backfire," Murray writes. In addition, Murray says, Porter believes that the "focus ... should be on value" because the "scandal of today's health care is that the quality is often shoddy." Porter also believes that, although "much of the effort to drive up value needs to happen in the private sector," the "government should take the lead in measuring health care quality and outcomes," according to Murray. He concludes, "If competition is going to rescue the U.S. health care system, it will have to be competition on price and quality"

Readers know I don't think competition will rescue our health system.  But I agree with Porter that we focus too much on cost and not nearly enough on quality.  Quality has bearing on cost as well -- medical errors are expensive, poor disease management leads to costly interventions, etc.  They shouldn't be viewed as separate -- quality affects cost and vice versa.   

But any single-payer or universal system must enact quality reforms  in order to be the best and most efficient system.  I'd focus on the following:

• Widespread adoption of electronic medical records and other HIT quality intiatives

• Redefined roles for PCPs to act as care managers

• Higher reimbursement rates for managing disease, as opposed to the current system which rewards for intervention

• Malpractice reforms that provide greater incentives to report errors, as well as preventing injury

• Major public health initiatives to reduce obesity and diabetes rates

Those are my top five -- what do you want?

Everything you wanted to know but were afraid to ask...

About HSA's!  Joe Paduda has a great round up.

General Motors speaks:

General Motors Chair Rick Wagoner last week said that the federal government and U.S. industries must address how increased health care costs have affected the economy and companies, the AP/Dayton Daily News reports. At a Houston Auto Show, Wagoner said that increased health care costs affect the growth of all companies, not only GM, which reported a loss of $4.8 billion for the fourth quarter and a loss of $8.6 billion for 2005. Wagoner attributed the losses in part to increased health care costs. "I want to be clear I'm not saying we expect the government to pick these expenses up. I think they've made it very clear they don't intend to do that, at least the current administration,"

It seems like a bit of a mixed message at the end with "we don't expect the government to pick these expenses up, at least not the current administration", but it's just preposturing; signalling openness for future Democratic leadership, but not threatening the current one.

In any case, GM could really use a break on their health costs.  Let's hope they last long enough to see one.

Fixing primary care

The American College of Physicians released a stark warning this week:

Primary care is on the verge of collapse," said the organization, a professional group which certifies internists, in a statement. "Very few young physicians are going into primary care and those already in practice are under such stress that they are looking for an exit strategy... The group has proposed a solution -- calling on federal policymakers to approve new ways of paying doctors that would put primary care doctors in charge of organizing a patient's care and giving patients more responsibility for monitoring their own health and scheduling regular visits.

On top of the inefficient way the U.S. health system provides insurance, our care delivery structure is quite perverted.  We have many many more specialists than other nations, many of whom have a "gate-keeper" system to centralize care. 

The U.S. doesn't need (or want, for that matter) a gate-keeper system as they exist in other countries. But we could do a much better job of streamlining care, and as ACP suggested, give primary care doctors' more responsibility for organizing a patient's care (as long as that greater responsibility results in a decreased patient load).   Americans loathed having needed a referral from their PCP everytime they set up an appointment with a specialist, so trying to implement that nation-wide won't work.  Instead, if we can put more focus on preventative care, and adopt a system where a PCP taking excellent care of their patient (pay for performance, anyone?) does result in a significant payment. 

Another benefit of more streamlined care is a reduction of errors.  If a PCP has all the information on medications and treatment for their patient, they can better evaluate if they're receiving unnecessary care (or not receiving necessary care).  But again, for this kind of system to function properly, PCPs must decrease their patient load.  That means insurance needs to start valuing care differently. 

There's also something to be said for utilizing more nurse practitioners and physician's assistants, who can provide the same, "My nose is running and I've got this awful cough" care at a much lower cost than M.D.'s.  If these practitioners become more in charge of urgent care it frees up PCPs to take on the role of health manager. 

HRT back again

A new study in the Journal of Women's Health reported that hormone replacement therapy may not have the horrible effects we think: 

Some researchers are testing a new theory, that hormone therapy is beneficial for the heart when it is initiated early, during a narrow "window of opportunity" around the time of menopause and before women develop an excessive buildup of atherosclerotic plaque.

A chief criticism of the hormone study, part of the national Women's Health Initiative, was that it included women much older than the average hormone user, who typically initiates therapy around the time of menopause. The average age of the participants in the study was 64. The average age of menopause is 51.4, and some studies suggest that women who initiate hormone therapy later may miss the chance to benefit from the treatment.

This month, a paper in The Journal of Women's Health added credence to that idea. It reported that women who started therapy soon after menopause reduced the risk of coronary heart disease 30 percent, but that the benefit appeared to diminish the longer women waited to initiate treatment.

I understand the criticism that the women in the study were older on average and that could have affected the results.  But there's two different things happening here.  One is that menopause is uncomfortable and frustrating.  The other is that medicine looks at menopause as a disease to "fix". 

Now that women are living longer there's good reason to try and relieve discomfort associated with menopause.  But we should be wary of the pharmaceutical industry's push for HRT.   They have a lot riding on widespread hormone use -- for years it was touted as a product that makes you "look younger". 

Talk about this "window of opportunity" is unsettling too, mostly because it's almost impossible to find out when that is.  For some women it might be 48, others 52.  And if you miss the window, you're taking a substantial risk. 

Hormones are still on the market, and you can believe doctors who say things like this are prescribing it for people who aren't  suffering from severe menopause symptoms:

"Personally, in my heart of hearts, I think there is a benefit," said Dr. Mary Jane Minkin, a clinical professor of obstetrics and gynecology at Yale. "However," Dr. Minkin said, "I'm politically incorrect if I say that." ... "Three years ago, the message was, 'You're going to die if you don't stop taki