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02/22/2017

Upcoming Podcasts: Medicaid Block Grants and What's the Evidence for Pay for Performance? (March 6th and 15th)

On March 6th I'll speak with Matt Salo, Executive Director of the National Association of Medicaid Directors, about Congressional Republican proposals to block grant or institute per capita caps in the Medicaid program.   

Considering the fact the Medicare and Medicaid programs along with private payers are committed to financially incenting healthcare providers or ever-increasingly paying for performance or outcomes, what does the evidence tell us about the success of pay for performance or P4P?  For example, studies show the UK's National Health Service experiment with P4P, that began over 10 years ago, has had no positive effect on quality or outcomes and systematic reviews of P4P have shown effects to be weak, mixed and/or inconclusive.   To discuss the research evidence in support of P4P and and the policy implications thereof, I'll be speaking on March 15th with Dr. Stephen B. Soumerai, Professor of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute.  

02/08/2017

Review of "Hell is A Very Small Place," (February 7th)

If you listened, or not, to my December 19th interview with Jean Casella (see below), one of the three editors of, "Hell is a Very Small Place, Voices from Solitary Confinement," here is my review of the work: http://thehealthcareblog.com/blog/2017/02/07/hell-is-a-very-small-place.

The essay begins with: 

It is well recognized that over the past several decades US prisons and jails have become the nation's largest inpatient psychiatric hospitals.  This is not surprising when you realize the majority of the US correctional population, the largest in the world at well over two million, suffers from mental illness.  Leaving aside the question of whether it is appropriate to incarcerate the mentally ill, at least those with serious mental illness, how we choose to treat a significant percent of mentally ill inmates is to place them in solitary confinement.  This means how we treat a significant percent of the mentally ill in this country is to torture them. 

 

02/07/2017

"The Case Against Sugar," A Conversation with the Author, Gary Taubes (February 6th)

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In his recent work, The Case Against Sugar, Gary Taubes argues not all calories are alike.  Sugar, or the consumption of sugar, causes elevated levels of insulin, or hyperinsulenema, and high levels of insulin drives fat accumulation.  Rather than obesity causing diabetes, Taubes argues, hyperinsulinemia causes both.   That there's been an 800% increase since 1960 in the consumption of sugar and approximate doubling of diagnosed cases of diabetes since 1990 cannot be a coincidence.  (Per the CDC, over the past 25 years the age-adjusted prevalence of diabetes increased by ≥50% in 42 states and by ≥100% in 18 states.)   Not only does sugar consumption drive the diabetes epidemic, Taubes argues it can also be correlated to hypertension, cancer, stroke and dementia.        

During this 35 minute conversation Mr. Taubes discusses the impetus for the book, sugar's relationship to elevated insulin levels and obesity and diabetes, the problem/s with the accepted belief that a "calorie is a calorie," the FDA's determination that sugar is GRAS (Generally Accepted as Safe), the role the Sugar Association has played in encouraging and defending sugar's consumption, the difficulty in scientifically proving sugar consumption is correlated to diabetes, hypertension and cancer among other prevalent serious and fatal illnesses, how much sugar do we consume and how much is too much, or how much sugar can we tolerate safely.    

Mr. Gary Taubes is the co-Founder of the Nutrition Science Initiative, and a science and health journalist. He is the author of Gary-TaubesWhy We Get Fat and Good Calories, Bad Calories. Gary has been a contributing correspondent for the journal Science since 1993, and has contributed articles as a freelancer to The Atlantic Monthly, The New York Times Magazine, Esquire, Slate, and numerous other publications.  His 1997 book, Bad Science was a New York Times Notable Book and a finalist for the Los Angeles Times Book Awards.  He is the only print journalist to be a three-time winner of the National Association of Science Writers Science-in-Society Journalism Award.  He is the recipient of a Robert Wood Johnson Foundation Independent Investigator Award in Health Policy Research.  Gary received his B.S. in physics from Harvard University, his M.S. in engineering from Stanford University, and his M.S. in journalism from Columbia University.

For more information on The Case Against Sugar go to: http://www.penguinrandomhouse.com/books/213737/the-case-against-sugar-by-gary-taubes/9780307701640/.

To learn more about the Nutrition Science Initiative go to: http://nusi.org/

01/26/2017

The Health Benefits of Marijuana and Related Regulatory Policies : A Conversation with Paul Armentano (January 24th)

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This past November, voters in seven states legalized marijuana either for medical or for recreational use.  Twenty-nine states have now legalized cannabis for medicinal use (and of these eight, along with the District of Columbia, for recreational use).   Despite growing state legalization, the debate concerning marijuana's health effects continues.  Recently, the National Academy of Sciences (NAS) published an extensive scientific review of research literature published since 1999 to reach nearly 100 conclusions about its therapeutic benefits including in the treatment for chronic pain in adults, chemotherapy-related nausea and vomiting and Multiple Sclerosis-related spasticity.  Despite state approval and demonstrated health benefits, at the federal level, marijuana is still classified as a Schedule I controlled substance (along with, e.g., heroin), and its use illegal.  

Mr. Paul Armentano is the Deputy Director of NORML, the National Organization for the Reform of Marijuana Laws.  He is Armentanoalso a faculty member at Oaksterdam University in Oakland, California.  His is the author of over 200 publications including more than a dozen contributions to textbooks and anthologies.  His most recent book-length work is, The Citizen's Guide to State-by-State Marijuana Laws (2015) and he is co-author of the 2013 volume, Marijuana is Safer: Why Are We Driving People to Drink?  Mr. Armentano was the principle investigator for the defense counsel in US v Schweder, the first federal evidentiary hearing since 1973 to challenge the constitutionality of cannabis as a Schedule I controlled substance.  He also served as an expert in a successful Canadian constitutional challenge, Crown v. Allard, preserving qualified patients right to grow cannabis at home.   Among other awards Mr. Armentano was the 2013 Freedom Law School Health Freedom Champion of the Year.  

The National Academy of Sciences' report, The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research is at: http://nationalacademies.org/hmd/reports/2017/health-effects-of-cannabis-and-cannabinoids.aspx.

For more information regarding NORML go to: http://norml.org/.

01/24/2017

"ACA Repeal and the Ethics of Belief," by David Introcaso (January 24th)

In 1877 William Clifford published an essay titled, The Ethics of Belief."  The essay became a seminal work in the field of ethics because Clifford posed a central question in life.  Is it wrong to believe something based on insufficient evidence? Is it wrong to oppose or support repeal of the Affordable Care Act absent "patient investigation" or based on "insufficient evidence"?  Are those, like the ship owner in Clifford's essay, then responsible for any and all adverse consequences resulting from repeal?

"ACA Repeal and the Ethics of Belief" is at: http://thehealthcareblog.com/blog/2017/01/23/aca-repeal-and-the-ethics-of-belief/.

01/07/2017

NIDCD's Efforts to Reduce Noise-Induced Hearing Loss: A Conversation with Dr. James Battey (January 6th, 2017)

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While there is evidence noise-induced hearing loss among adolescents has increased due to the use of smartphones and other mobile devices, the evidence to date is not compelling or is still the subject of scientific debate.  Nevertheless, noise induced-hearing loss is a legitimate concern and therefore a topic in need of health education to combat, particularly since exposure is frequently voluntary, the consequences are cumulative and because the effects typically do not manifest until years later. Already, it is estimated 12 to 15 percent of school age children have some hearing deficits attributable to noise exposure and in adults, 15 percent of 26 million Ameeicans between the ages 20 and 69 have noise induced hearing loss.  The consequences can be significant.  In children, for example, hearing loss can delay language development, reduce educational achievement, produce social isolation and compromise quality of life.   

During this 21 minute conversation Dr. Battey discusses the effects of being deaf, the physiological causes of deafness, the evidence for noise induced hearing loss and moreover the impetus for the NIDCD's "It's a Noisy Planet" and the educational program's goals, targeted audiences, activities and success or impact to date.  

Since 1998 Dr. James Battey has served as Director of the NIH's NIDCD.  Previously he served as the Institute's Director of Battey_7486Intramural Research.   He has also served as an Investigator and Section Chief at the NIH's National Cancer Institute and the National Institute of Neurological Disorders and Stroke.  Dr. Battey received his undergraduate degree in physics at the California Institute of Technology and his MD and Ph.D. in biophysics at Stanford University School of Medicine.  He did his residency training in pediatrics also at Stanford and did postdoctoral training in genetics at Harvard Medical School. 

For information concerning NIDCD's "It's a Noisy Planet" go to: https://www.noisyplanet.nidcd.nih.gov/.

For a review article concerning noise induced hearing loss among children, see, for example, Robert V. Harrison, "The Prevention of Noise Induced Hearing Loss in Children," International Journal of Pediatrics (2012) at: https://www.hindawi.com/journals/ijpedi/2012/473541/

12/20/2016

Solitary Confinement: the Least Discussed & Most Unknown Public Health Crisis in America: A Conversation with Jean Casella (December 19th)

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On any given day US prisons and jails hold between 80,000 and 120,000 men, women and children in solitary confinement.   A significant percent of these individuals enter solitary with a mental disease and a similar percent of those held in isolation for extended periods of time develop severe psychiatric illnesses that include self amputation and suicidality.  (US prisons and jails constitute the largest psychiatric hospitals in the country.)  The UN Special Rapporteur on Torture and Other Cruel, Inhuman or Degrading Treatment and Punishment, Juan E. Mendez, has concluded solitary confinement for more than 15 days constitutes torture.  In Hell is a Very Small Place, Voices from Solitary Confinement," edited by Jean Casella, James Ridgeway and Sarah Shourd, 16 former and current solitary confinement inmates discuss their experience in solitary and  two physicians and three professors (in law, political science and philosophy) discuss its physical and psychological effects and legal justification. 

During this 32 minute conversation, Ms Casella provides an overview of Hell Is a Very Small Place.  She explains why inmates are placed in solitary confinement, for how long and describes conditions under confinement.  She provides an overview of the psychological effects of solitary noted by contributing authors Dr. Stuart Grassian and Dr. Terry Kupers.  She addresses whether solitary confinement constitutes torture, explains how inmates attempt to keep their sanity, explains to what extent private sector profit making contributes to the practice and discusses what continued progress, if any, may be made under a new, incoming administration. 

Ms. Jean Casella is co-director of Solitary Watch, a web-based watchdog project that investigates, documents, and Caselladisseminated information about solitary confinement in US prisons and jails.  Prior to co-founding Solitary Watch in 2009, Ms. Casella managed several mission-driven book and magazine publishers including Thunder's Mouth Press and the Feminist Press.  Jean's writing has appeared in The Nation, Mother Jones, The Guardian, Al Jazerra, and other publications and media outlets.  The Hell is a Very Small Place anthology edited was published by The New Press in February.  For her work on solitary confinement, Jean was awarded a Soros Media Fellowship in 2012. 

For more information concerning Hell Is a Very Small Place go to: http://thenewpress.com/books/hell-very-small-place.

The UN Special Rapporteur's report is at: http://solitaryconfinement.org/uploads/SpecRapTortureAug2011.pdf

For another physician's review of solitary confinement, see, for example, Dr. Atul Gawande's essay titled,"Hellhole," in the March 30, 2009 issue of The New Yorker.  At: http://www.newyorker.com/magazine/2009/03/30/hellhole

12/06/2016

Will the Republicans Repeal the Affordable Care Act and Be Able to Replace It: A Conversation with Chris Jennings (December 5th)

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With the election of Donald Trump Congressional Republicans are poised to repeal the Affordable Care Act (ACA) within the first 100 days of the 115th Congress via the budget reconciliation process.  (At some future date they are pledging to draft ACA replacement language or legislation.)  The expectation is repeal would have an effective date of 2018 or 2019, or after the mid-term Congressional elections.  However, many if not most health policy experts agree the simple act of repeal would cause such instability state insurance marketplaces would collapse long before repeal would, legally, go into effect.  Congressional Republican leadership is also promising to move major Medicare, via premium support and major Medicaid legislation, via block grants or per capita caps, though the upcoming Congress.       

During this 23 minute conversation Chris Jennings discusses whether, and moreover how if at all, Congressional Republicans can repeal the ACA with an out-year effective date without fatally damaging state insurance marketplaces, the likely consequences of a simple repeal (without replace), when and how will Republicans will replace the ACA and whether that effort would garner any Democratic interest or support, what substantively explains Republican opposition to the current law and what might Republican leadership do to reform the Medicaid program and its likely effects.

Chris Jennings is currently Founder and President of Jennings Policy Strategies, a DC-based policy firm where he consults Jenningswith foundations, purchasers and other aligned stakeholders on policies to ensure higher quality, more affordable health care for all Americans.  Previously, Mr. Jennings served as Deputy Assistant for Health Policy to President Obama and for eight years as White House Health Care Adviser to President Clinton.   Prior still he served for a decade in the US Senate for Senators Glenn, Pryor and Melcher where he worked on Medicaid CHIP, HIPAA, PDUFA, major Medicare reforms in the 1997 Balanced Budget Act and related work concerning long term care, prescription drug coverage, rural healthcare and other related issues.  Chris has been a campaign adviser to six Democratic presidential campaigns and is a frequent contributor on health reform issues to the New England Journal of Medicine and numerous other scholarly journals, periodicals and newspapers.   

 

12/01/2016

The Pros and Cons (or Imperfections) in Rating Hospital Care Quality: A Conversation with Consumer Reports' Doris Peter (November 30th)

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Though comparatively late to adopt quality ratings, many health care products and services are today quality rated.  For example, CMS rates hospital, nursing home and home health care care quality along with Medicare Advantage insurance and prescription drug, or Part D plans.  Quality performance is a factor in calculating rewards and penalties in Medicare pay for performance agreements, for example, in scoring earned shared savings for Accountable Care Organizations.   Though today common, rating care quality is not without criticism.  For example, researchers question the validity of how component or domain scores are weighted or clustered, the absence or inadequacy of risk adjustment, meaningfulness to patients, patient literacy/numeracy limitations and unintended negative consequences.     

During this 21 minute conversation, Dr. Peter discusses why Consumer Reports rates hospital care quality, the methodology used in scoring hospital care quality, specifically types of care quality, for example prevalence of hospital-acquired infections, the response to ratings by hospitals, use by patients or consumers, the imperfections or limitations in rating hospital care quality, unintended negative consequences and how Consumer Reports intends to improve upon its work in the near term.

Dr. Doris Peter is the Director of Consumer Reports Health Ratings Center, a part of the nonprofit organization, Consumer Doris Peter Reports.   Beyond hospitals her team rates other health care services including physicians and insurance plans and as well health care products, e.g., drugs.  Dr. Peter is also the Principal Investigator of a grant from the Consumer and Prescriber Education Grant Project that helps consumers understand safety, effectiveness and the cost of prescription and over-the-counter medications.  Prior to joining Consumer Reports Dr. Peter was an editor and then publisher of the nonprofit organization, The Medical Letter, and then North American editor for an international evidence-based medicine journal.  Dr Peter is a neurobiologist by training, earning her Ph.D. at UCLA.  She completed a postdoctoral fellowship in cellular biophysics at Rockefeller University.

For more on Consumer Reports hospital quality ratings efforts go to: http://www.consumerreports.org/cro/health/doctors-and-hospitals/index.htm

 

11/17/2016

What Explains the Opioid Epidemic? Dr. Anna Lembke Discusses Her Recent Work, "Drug Dealer, MD" (November 16th)

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As has been widely reported the US has faced an opioid addiction epidemic over the past decade.  Opioid-related overdose deaths have quadrupled in recent years.  (Drug overdose deaths, in sum, now equal or exceed auto accident fatalities.)   What explains the dramatic increase use and addiction to these medicines?  In Drug Dealer, MD, recently published by Johns Hopkins University Press, Dr. Anna Lembke presents a nuanced explanation of what is a highly complex problem. 

The 30 minute conversation begins with Dr. Lembke briefly explaining work's title, Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked and Why It's So Hard to Stop.  Moreover, Dr. Lembke discusses several of the numerous reasons that explain the opioid addiction epidemic, i.e., patient and prescribing physician behavior, organized medicine's contribution, pharmaceutical industry marketing strategies and market forces that all contribute to fostering the epidemic.

Dr. Anna Lembke is an Assistant Professor of Psychiatry and Behavioral Sciences at Stanford University.  She is also a faculty Lembkemember at the Stanford University School of Medicine, Program Director for the Sanford University Addiction Medicine Fellowship and Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic.  She is also a Diplomate of the American Board of Psychiatry and Neurology and a Diplomate of the American Board of Addiction Medicine.  Dr. Lembke has published over 50 peer-reviewed articles, chapters and commentaries in numerous journals including the New England Journal of Medicine and the Journal of the American Medical Association and the Journal of General Internal Medicine and Addiction. Dr. Lembke recieved her undergraduate degree in Humanities from Yale University and her medical degree from Stanford. 

For more information on Dr. Lembke's work go to: https://jhupbooks.press.jhu.edu/content/drug-dealer-md