In 2001 in 5 states sampled, it was found that medical problems contributed to at least 46.2% of all bankruptcies. Since then, health costs and the numbers of un- and underinsured have increased, and bankruptcy laws have tightened. Despite these factors, medical related bankruptcy increased to 62.1% of all bankruptcies in 2007. Illness and medical bills contribute to a large and increasing share of US bankruptcies.
Abstract
Background
Our 2001 study in 5 states found that medical problems contributed to at least 46.2% of all bankruptcies. Since then, health costs and the numbers of un- and underinsured have increased, and bankruptcy laws have tightened.
Methods
We surveyed a random national sample of 2314 bankruptcy filers in 2007, abstracted their court records, and interviewed 1032 of them. We designated bankruptcies as “medical” based on debtors' stated reasons for filing, income loss due to illness, and the magnitude of their medical debts.
Results
Using a conservative definition, 62.1% of all bankruptcies in 2007 were medical; 92% of these medical debtors had medical debts over $5000, or 10% of pretax family income. The rest met criteria for medical bankruptcy because they had lost significant income due to illness or mortgaged a home to pay medical bills. Most medical debtors were well educated, owned homes, and had middle-class occupations. Three quarters had health insurance. Using identical definitions in 2001 and 2007, the share of bankruptcies attributable to medical problems rose by 49.6%. In logistic regression analysis controlling for demographic factors, the odds that a bankruptcy had a medical cause was 2.38-fold higher in 2007 than in 2001.
Conclusions
Illness and medical bills contribute to a large and increasing share of US bankruptcies.
To read this article in its entirety, please visit our website.
-- David U. Himmelstein, MD, Deborah Thorne, PhD, Elizabeth Warren, JD, Steffie Woolhandler, MD, MPH
This article was originally published in the August 2009 issue of The American Journal of Medicine.
Jumat, 28 Agustus 2009
Only in America: Bankruptcy Due to Health Care Costs
The article by Himmelstein et al in the August 2009 issue of the The American Journal of Medicine documents that health care expenses were the most common cause of bankruptcy in the United States in 2007, accounting for 62% of US bankruptcies compared with 8% in 1981.
Most bankruptcies occurred in middle-class citizens with health insurance, further evidence that our current health care system, based on for-profit, employment-based health insurance, is not working. Millions of Americans have limited access to health care because they cannot afford health insurance. Millions of others, such as those who have to file for bankruptcy because of health care costs, have inadequate health insurance. It is estimated that 1 in 5 Americans goes without health insurance or has inadequate health insurance.
Why is the United States, one of the richest countries in the world, the only major industrial nation that is unable to provide access to health care to all its citizens? Are there any other nations whose citizens have to declare bankruptcy because of health care expenses?
To read this article in its entirety, please visit our website.
-- James E. Dalen, MD, MPH
This article was originally published in the August 2009 issue of The American Journal of Medicine.
Most bankruptcies occurred in middle-class citizens with health insurance, further evidence that our current health care system, based on for-profit, employment-based health insurance, is not working. Millions of Americans have limited access to health care because they cannot afford health insurance. Millions of others, such as those who have to file for bankruptcy because of health care costs, have inadequate health insurance. It is estimated that 1 in 5 Americans goes without health insurance or has inadequate health insurance.
Why is the United States, one of the richest countries in the world, the only major industrial nation that is unable to provide access to health care to all its citizens? Are there any other nations whose citizens have to declare bankruptcy because of health care expenses?
To read this article in its entirety, please visit our website.
-- James E. Dalen, MD, MPH
This article was originally published in the August 2009 issue of The American Journal of Medicine.
“Common Sense Is Not So Common” (What We All Need to Remember)—Part One
Common Sense Is Not So Common.
Voltaire (Francois Marie Arouet, 1694-1778)
Dictionnaire Philosophique, 1764
This editorial is the second time I have discussed clinical aphorisms that have proved useful for me during more than 30 years of inpatient and outpatient attending at 4 US medical schools. The last time I put this list of aphorisms together, it contained 10 items. The current commentary will be published sequentially in 2 parts with 8 aphorisms in part I and 7 additional items in part II for a total of 15.
Rule 1: Common things occur commonly. I make this point continuously to medical students and residents. Sometimes young clinicians will suggest an unusual diagnosis for a patient with the hope of being the only doctor to make the correct diagnosis. More experienced clinicians believe the correct diagnosis is usually something common. For example, consider a patient with an enlarged spleen. In North America, splenomegaly rarely results from entities such as primary lymphoma of the spleen or malaria. Rather, splenomegaly is often caused by portal hypertension or mononucleosis. One of my first, and best, residents during my internship told me “If it looks like a horse, whinnies like a horse, and smells like a horse, don't expect a zebra to appear” (Stone N, MD, personal communication, 1970).
The experienced clinician is aware of the relative incidence of various illnesses in his/her community, and, unless there are unusual features in a particular patient's clinical picture, one should always seek one of the diagnoses most common in the community where one practices. For example, on moving to Arizona, I was amazed to discover how common coccidiomycosis pneumonia was in our hospital population. I had learned about this illness while studying and working in Boston. However, I had never seen an example of this disease entity and thought that it was a rarity. This is definitely not the case in Arizona where coccidiomycosis pneumonitis is common and should always be considered in the differential diagnosis of a pulmonary infiltrate.
Rule 2: Common sense occurs uncommonly. This aphorism is usually attributed to Voltaire. Over the years, I have seen many violations of this important rule in clinical medicine. Physicians should exercise common sense before ordering tests or performing therapeutic interventions. Examples abound in support of this rule. Recently, I saw a 60-year-old diabetic woman in my office. She had been admitted to our hospital several weeks earlier with a single bout of rest angina. Her cardiac catheterization revealed modest coronary arterial stenoses, and she was placed on medical therapy with brand name medications by another cardiologist: a statin, an angiotensin receptor blocker, and clopidogrel. Subsequently, I first saw her in my office. At that time, she and her family told me that they had paid more than $500 for 1 month's supply of the medicines that had been prescribed in the hospital. I quickly altered her regimen to include generic forms of a statin and an angiotensin-converting enzyme inhibitor, as well as 325 mg of aspirin. These new generic prescriptions would cost the patient less than $20 per month. Common sense should have been used earlier by the inpatient attending physician simply by informing the patient that generic brands cost less than brand name pharmaceuticals. As noted by Harvey Cushing (1869-1939), “Three-fifths of the practice of medicine depends on common sense, knowledge of people and of human reactions.” I would add knowledge of the patient's ability to pay for the medicines prescribed.
Rule 3: The less a procedure is indicated the more likely that its use will be accompanied by complications. This rule advises clinicians to ensure that every procedure or test ordered has a reasonable probability of altering patient management. An example of this aphorism in practice involved a healthy 55-year-old man without coronary heart disease risk factors. He became anxious when a neighbor had an acute myocardial infarction. His doctor suggested that he undergo a coronary calcium computed tomography scan. This test revealed modest coronary calcifications. The patient became more anxious when he heard the results of his computed tomography scan, and he convinced his physician that he needed a coronary angiogram. The angiogram was unremarkable, but the catheterization resulted in a large groin hematoma and pseudoaneurysm that required vascular surgical repair. If I had been involved in this patient's initial care, reassurance or, at most, a Bruce protocol electrocardiographically monitored exercise test, would have been my approach.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
This article was originally published in the August 2009 issue of The American Journal of Medicine.
Voltaire (Francois Marie Arouet, 1694-1778)
Dictionnaire Philosophique, 1764
This editorial is the second time I have discussed clinical aphorisms that have proved useful for me during more than 30 years of inpatient and outpatient attending at 4 US medical schools. The last time I put this list of aphorisms together, it contained 10 items. The current commentary will be published sequentially in 2 parts with 8 aphorisms in part I and 7 additional items in part II for a total of 15.
Rule 1: Common things occur commonly. I make this point continuously to medical students and residents. Sometimes young clinicians will suggest an unusual diagnosis for a patient with the hope of being the only doctor to make the correct diagnosis. More experienced clinicians believe the correct diagnosis is usually something common. For example, consider a patient with an enlarged spleen. In North America, splenomegaly rarely results from entities such as primary lymphoma of the spleen or malaria. Rather, splenomegaly is often caused by portal hypertension or mononucleosis. One of my first, and best, residents during my internship told me “If it looks like a horse, whinnies like a horse, and smells like a horse, don't expect a zebra to appear” (Stone N, MD, personal communication, 1970).
The experienced clinician is aware of the relative incidence of various illnesses in his/her community, and, unless there are unusual features in a particular patient's clinical picture, one should always seek one of the diagnoses most common in the community where one practices. For example, on moving to Arizona, I was amazed to discover how common coccidiomycosis pneumonia was in our hospital population. I had learned about this illness while studying and working in Boston. However, I had never seen an example of this disease entity and thought that it was a rarity. This is definitely not the case in Arizona where coccidiomycosis pneumonitis is common and should always be considered in the differential diagnosis of a pulmonary infiltrate.
Rule 2: Common sense occurs uncommonly. This aphorism is usually attributed to Voltaire. Over the years, I have seen many violations of this important rule in clinical medicine. Physicians should exercise common sense before ordering tests or performing therapeutic interventions. Examples abound in support of this rule. Recently, I saw a 60-year-old diabetic woman in my office. She had been admitted to our hospital several weeks earlier with a single bout of rest angina. Her cardiac catheterization revealed modest coronary arterial stenoses, and she was placed on medical therapy with brand name medications by another cardiologist: a statin, an angiotensin receptor blocker, and clopidogrel. Subsequently, I first saw her in my office. At that time, she and her family told me that they had paid more than $500 for 1 month's supply of the medicines that had been prescribed in the hospital. I quickly altered her regimen to include generic forms of a statin and an angiotensin-converting enzyme inhibitor, as well as 325 mg of aspirin. These new generic prescriptions would cost the patient less than $20 per month. Common sense should have been used earlier by the inpatient attending physician simply by informing the patient that generic brands cost less than brand name pharmaceuticals. As noted by Harvey Cushing (1869-1939), “Three-fifths of the practice of medicine depends on common sense, knowledge of people and of human reactions.” I would add knowledge of the patient's ability to pay for the medicines prescribed.
Rule 3: The less a procedure is indicated the more likely that its use will be accompanied by complications. This rule advises clinicians to ensure that every procedure or test ordered has a reasonable probability of altering patient management. An example of this aphorism in practice involved a healthy 55-year-old man without coronary heart disease risk factors. He became anxious when a neighbor had an acute myocardial infarction. His doctor suggested that he undergo a coronary calcium computed tomography scan. This test revealed modest coronary calcifications. The patient became more anxious when he heard the results of his computed tomography scan, and he convinced his physician that he needed a coronary angiogram. The angiogram was unremarkable, but the catheterization resulted in a large groin hematoma and pseudoaneurysm that required vascular surgical repair. If I had been involved in this patient's initial care, reassurance or, at most, a Bruce protocol electrocardiographically monitored exercise test, would have been my approach.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
This article was originally published in the August 2009 issue of The American Journal of Medicine.
It's Time to Bail Out Seniors Trapped in the Medicare Donut Hole!
Medicare D, which became effective in January of 2006, was a major step forward in providing prescription drug coverage to one segment of our population: those age 65 and older. As of 2009, 90% of all seniors (Medicare beneficiaries) had signed up for Medicare D, which is voluntary, or had other insurance coverage for prescription drugs.
The Medicare population accounts for one third of all prescription drug use in the US. The vast majority (87%) of seniors have at least one chronic condition that requires life-long medication, and more than 45% have 3 or more chronic conditions. The average number of prescription drugs for seniors with one of the commonest chronic conditions, congestive heart failure, was 7.5 with an annual cost of $3823 in 2001. The health of our Medicare population is dependent on their being able to afford prescription drugs.
Unfortunately, 2 features of the Medicare D legislation jeopardize the ability of seniors to afford the drugs they require. The legislation forbids Medicare from negotiating drug prices with drug manufacturers. Unlike the Department of Defense, the Veterans Administration, and Medicaid, which are able to negotiate discounts of 30 to 50%, Medicare is forced to pay the manufacturers' asking price. As a result, Medicare and Medicare beneficiaries pay more for prescription drugs than the citizens of any other country. Medicare pays 30% more for prescription drugs than Medicaid pays. In 2 years (2006 and 2007) Medicare paid $3.7 billion more than Medicaid would have paid for the same prescription drugs.
The second feature of the legislation that jeopardizes the ability of seniors to afford prescription drugs is the infamous “donut hole.” Once a deductible of $250 has been paid by the senior, Medicare pays 75% of the cost of drugs and the senior pays 25% until the total amount paid by Medicare and the patient reaches $2250. At that point, the senior pays 100% out of pocket until the total amount paid by the patient and Medicare reaches a catastrophic limit of $5100. After that point has been reached, the senior is freed from the donut hole and Medicare pays 95% of further prescription costs. In one study, only 3%, and in another study, only 4% of seniors falling into the donut hole emerged to receive catastrophic coverage.
To read this article in its entirety, please visit our website.
-- James E. Dalen, MD, MPH
This article was originally published in the July 2009 issue of The American Journal of Medicine.
The Medicare population accounts for one third of all prescription drug use in the US. The vast majority (87%) of seniors have at least one chronic condition that requires life-long medication, and more than 45% have 3 or more chronic conditions. The average number of prescription drugs for seniors with one of the commonest chronic conditions, congestive heart failure, was 7.5 with an annual cost of $3823 in 2001. The health of our Medicare population is dependent on their being able to afford prescription drugs.
Unfortunately, 2 features of the Medicare D legislation jeopardize the ability of seniors to afford the drugs they require. The legislation forbids Medicare from negotiating drug prices with drug manufacturers. Unlike the Department of Defense, the Veterans Administration, and Medicaid, which are able to negotiate discounts of 30 to 50%, Medicare is forced to pay the manufacturers' asking price. As a result, Medicare and Medicare beneficiaries pay more for prescription drugs than the citizens of any other country. Medicare pays 30% more for prescription drugs than Medicaid pays. In 2 years (2006 and 2007) Medicare paid $3.7 billion more than Medicaid would have paid for the same prescription drugs.
The second feature of the legislation that jeopardizes the ability of seniors to afford prescription drugs is the infamous “donut hole.” Once a deductible of $250 has been paid by the senior, Medicare pays 75% of the cost of drugs and the senior pays 25% until the total amount paid by Medicare and the patient reaches $2250. At that point, the senior pays 100% out of pocket until the total amount paid by the patient and Medicare reaches a catastrophic limit of $5100. After that point has been reached, the senior is freed from the donut hole and Medicare pays 95% of further prescription costs. In one study, only 3%, and in another study, only 4% of seniors falling into the donut hole emerged to receive catastrophic coverage.
To read this article in its entirety, please visit our website.
-- James E. Dalen, MD, MPH
This article was originally published in the July 2009 issue of The American Journal of Medicine.
“Hey, Doc, Is It OK for Me to Drink Coffee?”
Many of my patients with coronary artery disease, diabetes, or hypertension have been warned at various times in their lives to avoid caffeinated coffee because they had been informed that drinking caffeinated coffee could result in increased blood pressure, worsening of diabetic control, and might even trigger a myocardial infarction. Some of my patients also worry that drinking caffeinated coffee might cause cancer. This editorial will briefly cite the now-voluminous evidence that caffeinated coffee in moderate doses (1-3 cups per day in some studies and more in other investigations) is not associated with clinically relevant increases in blood pressure, serum cholesterol levels, myocardial infarction, or various malignancies.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
This article was originally published in the July 2009 issue of The American Journal of Medicine.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
This article was originally published in the July 2009 issue of The American Journal of Medicine.
The Effect of a Hypertension Self-Management Intervention on Diabetes and Cholesterol Control
Although most chronic disease self-management programs target specific disease outcomes, they may have unintended but beneficial effects on other comorbid chronic conditions.
Abstract
Background
Most patient chronic disease self-management interventions target single-disease outcomes. We evaluated the effect of a tailored hypertension self-management intervention on the unintended targets of glycosylated hemoglobin (HbA1c) and low-density lipoprotein cholesterol (LDL-C).
Methods
We evaluated patients from the Veterans Study to Improve the Control of Hypertension, a 2-year randomized controlled trial. Patients received either a hypertension self-management intervention delivered by a nurse over the telephone or usual care. Although the study focused on hypertension self-management, we compared changes in HbA1c among a subgroup of 216 patients with diabetes and LDL-C among 528 patients with measurements during the study period. Changes in these laboratory values over time were compared between the 2 treatment groups using linear mixed-effects models.
Results
For the patients with diabetes, the hypertension self-management intervention resulted in a 0.46% reduction in HbA1c over 2 years compared with usual care (95% confidence interval, 0.04%-0.89%; P = .03). For LDL-C, there was a minimal 0.9 mg/dL between-group difference that was not statistically significant (95% confidence interval, −7.3-5.6 mg/dL; P = .79).
Conclusions
There was a significant effect of the self-management intervention on the unintended target of HbA1c,but not LDL-C. Chronic disease self-management interventions might have “spill-over” effects on patients' comorbid chronic conditions.
To read this article in its entirety, please visit our website.
-- Benjamin J. Powers, MD, Maren K. Olsen, PhD, Eugene Z. Oddone, MD, MHS, Hayden B. Bosworth, PhD
This article was originally published in the July 2009 issue of The American Journal of Medicine.
Abstract
Background
Most patient chronic disease self-management interventions target single-disease outcomes. We evaluated the effect of a tailored hypertension self-management intervention on the unintended targets of glycosylated hemoglobin (HbA1c) and low-density lipoprotein cholesterol (LDL-C).
Methods
We evaluated patients from the Veterans Study to Improve the Control of Hypertension, a 2-year randomized controlled trial. Patients received either a hypertension self-management intervention delivered by a nurse over the telephone or usual care. Although the study focused on hypertension self-management, we compared changes in HbA1c among a subgroup of 216 patients with diabetes and LDL-C among 528 patients with measurements during the study period. Changes in these laboratory values over time were compared between the 2 treatment groups using linear mixed-effects models.
Results
For the patients with diabetes, the hypertension self-management intervention resulted in a 0.46% reduction in HbA1c over 2 years compared with usual care (95% confidence interval, 0.04%-0.89%; P = .03). For LDL-C, there was a minimal 0.9 mg/dL between-group difference that was not statistically significant (95% confidence interval, −7.3-5.6 mg/dL; P = .79).
Conclusions
There was a significant effect of the self-management intervention on the unintended target of HbA1c,but not LDL-C. Chronic disease self-management interventions might have “spill-over” effects on patients' comorbid chronic conditions.
To read this article in its entirety, please visit our website.
-- Benjamin J. Powers, MD, Maren K. Olsen, PhD, Eugene Z. Oddone, MD, MHS, Hayden B. Bosworth, PhD
This article was originally published in the July 2009 issue of The American Journal of Medicine.
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