The mandate to ensure the availability to quality care while also containing and reducing the cost of healthcare in the United States remains an illusion to those entities tasked with this accomplishment. Nevertheless, since the passage of the ACA, there have been both macro and micro level changes within the industry specific to Medicare reimbursements.

Primary macro-level changes that have affected the healthcare delivery system can be noted in cost containment reforms to reduce Medicare and Medicaid spending through restructuring payment reimbursements. This has led to a surge in the implementation of Accountable Care Organizations (ACOs) and the Patient Centered Care Models. It is believed that ACOs are the greatest hope for the much needed and desired delivery system reform.

Operational changes affected by administrative simplification initiatives have taken a critical role in the fiscal solvency, directly affecting the revenue streams for providers and clinicians. Many are facing long and unexplained delays in reimbursements for their clients who are Medicare beneficiaries. The implementation of the HIPAA Version 5010′s deadline initially set for January 1, 2012, has come and gone, leaving practices that were unsuccessful in fully implementing the change faced with extreme delays in reimbursements. The Centers for Medicare and Medicaid Services (CMS) provided a PDF updated document addressing some of the concerns linked to the delayed reimbursements on March 2, 2012. The implementation deadline was then pushed to June of 2012. News on the front indicates that CMS has initiated a program with Emdeon to research the viability of implementing the HIPAA Transaction Version 6020.

Another area of great concern within the healthcare community is the implementation of the ICD-10 codes, along with the consistent HIPAA transactions updates. The push for greater access to information by creating wide-spread HIT systems has created a lack of cohesion within transferring systems. Looming implementation deadlines add to an already stressful environment for practicing clinicians who are struggling financially as a result of the delayed reimbursements from Medicare.

In February 2013, with CMS struggling to overcome a growing level of negative response from practicing clinicians regarding the overall Medicare program, the agency announced continued implementation changes provided through the ACA. These efforts include a proposal to update the 2014 rate-book to mirror the most current Fee-For-Service (FFS) costs, alignment restructuring changes of Medicare Advantage (MA) benchmarks with Medicare FFS costs, and basing some of the MA payment on the quality of the plan. In addition, CMS has proposed a 1.5% increase above the 2013 MA plan payment for 2014, resulting in a 4.91% total adjustment.

Most likely, the continued efforts by health care professionals and organizations to express the ongoing discontent among clinicians regarding the overall state of the Medicare program, served as a catalyst for CMS’ 2013 legislative proposals, which included much needed provider payment incentives. With approximately 92% of Medicare beneficiaries enrolled in the voluntary Medicare Part B program, this should relate to a greater volume of pay-outs for provider incentives in effecting higher levels of quality care. As Medicare Part B assists in covering mental health services primarily provided outside of a hospital setting, this translates into greater opportunity for mental health clinicians who enroll as Medicare providers to offer their services.

As the political debate continues over the ACA, many practicing clinicians remain focused on issues regarding the Medicare program. CMS recognizes the need to ensure cooperation within the health care industry to ensure greater access to quality care for all US citizens as mandated under the ACA. As such, this should continue to effect both macro and micro level changes within the health care industry specific to Medicare reimbursements.

References

Leibenluft RF (2011). ACOs and the enforcement of fraud, abuse, and antitrust laws. The New England journal of medicine, 364 (2), 99-101 PMID: 21175308

U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, (2013, February 15). Details for Rate Year: 2014.

U.S. Department of Health and Human Services, Centers for Medicare and
Medicaid Services, (2012, March 4). Medicare Advantage Rates and Statistics.

U.S. Department of Health and Human Services, Centers for Medicare and
Medicaid Services, (2012, June). Medicare and Your Mental Health Benefits.

U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, (2012, March 7). Version 5010 and D.0 & 3.0.

U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, (2013). Fiscal 2013 Budget in Brief: Strengthening Health and Opportunity for All Americans.

Image via S_L / Shutterstock.

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The medical community continues to maintain a high profile in discussion that will further impact the roll-out of the ACA. In particular, the American Academy of Neurology (AAN), has created its own resources to assist members in discovering alternative payment methods, as well as engaging in incentive programs that assist in avoiding payment penalties. Through the efforts of the AAN and other health care agencies and professionals, not only can the interests of the general public be preserved, but also the professional and business interests of those medical entities will remain intact.

The issue of access to research and technology has once again reared its inquisitive head in an effort to spark greater continuity within the research community. On February 14, 2013, the Fair Access to Science and Technology Research (FASTR) was introduced to Congress as H.R. 708 and S. 350. Supported by both the American Library Association (ALA) and The Scholarly Publishing and Academic Resources Coalition (SPARC), the bill is designed to provide a platform for greater sharing of publicly funded research articles. It is believed that by opening access to these findings, a higher level of productivity in science and technology research, as well as a higher level of academic achievement can be attained.

Since the passage of the ACA on March 23, 2010, The Agency for Healthcare Research and Quality (AHRQ) continues to remain vigilant in its efforts to clarify challenges faced within the healthcare industry. Most recently, the European Federation of Neurological Societies released new guidelines for the diagnosis and management of Alzheimer’s disease, which has been included in the AHRQ data base. Primary issues addressed include providing an evidenced-based, peer-reviewed statement of guidance for practice to psychiatrists, geriatricians, and clinical neurologists, as well as qualified physician specialists charged with the care of patients with Alzheimer’s Disease.

The ACA also includes several provisions to direct discretionary spending toward specific components that increase the production and productivity of high-risk disease management, such as Alzheimer’s Disease and Parkinson’s Disease. The ACA increased discretionary spending on a number of fronts, opening the door to greater research possibilities. Section 10409 of the ACA allocated approximately $10 million in 2012, with an additional $50 million requested in 2013 for biomedical research. Under Section 10409 these changes reflect the establishment of a Cures Acceleration Network (CAN) program, overseen by the Office of the NIH which will award cooperative agreements, contracts, and/or grants to support the development of treatments for conditions and/or diseases that may be considered uncommon, and where market incentives are deficient. Eligible recipients include both private and public participants, research institutions, biotechnology companies, pharmaceutical companies, research institutions, higher education institutions, medical centers, patient advocacy organizations, academic research institutions, and disease advocacy organizations.

The NIH continues to reach out to the medical community in an effort to provide much needed funding for research and development. Both the government and the private sector recognize the continued need for progressive and consistent tools for advancement in chronic disease management. Although primary focus remains centered on the health insurance mandate, the stage has been set to increase both funding and transparency in biomedical research and development.

References

American Academy of Neurology (2013), The Patient Protection and Affordable Care Act Largely Ruled Constitutional: Now What?.

American Library Association (2013)., The Fair Access to Science and Technology Research (FASTR).

Redhead, C., Colello, K., Heisler, E., Lister, S., Sara, A. (2012, October 1). Discretionary Spending in the Patient Protection and Affordable Care Act (ACA). Congressional Research Services (R41390).

U.S. Department of health and Human Services, Agency for Healthcare Research and Quality (n.d.). National Guidelines Clearing House: EFNS guidelines for the diagnosis and management of Alzheimer’s disease.

Image via Mesut Dogan / Shutterstock.

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Hand-in-hand with other techniques, you can really help lubricate the channel to a new chapter in a person’s life. Or, if you are a sales person, “help” the person buy something they don’t really need. I say this, not as an assault on sales people, but to point out that, if you must use such techniques to sell something, I must raise the ethical questions, “Why is such psychological firepower necessary to sell someone what they need? Are they resisting the truth? If so, who are you to have a higher truth?” Of course, those questions are merely red herrings. The answer is: follow the money.

And it is in this spirit that I raise another question, “Why is so much psychological firepower needed on American political TV?” As a student of persuasion, I am observing very sophisticated techniques used very consistently; so consistently, that I have no doubt that there is training and networking toward perfecting them. I’m also sure that, just as I am finding with psychotherapy, many of these political media types are more intuitive than studied in their skills. But why? Again, follow the money.

Here one of my favorite (in a bad way) skills. Watch for them when you see people debating politics on TV or elsewhere.

Targeted interruption: This is an amazing ability to know exactly when to interrupt the other party so they will not effectively get their points across. After years of watching this, I finally saw someone confronted on this behavior. But Noam Chomsky, a famous intellectual and linguist no less, was effectively undermined at the hands of an expert interrupter, William F. Buckley. Buckley was so talented, he almost made apartheid sound like it was a boon to civilization.

An ethical use of interruption (and priming): A therapist may use forms of interruption to prevent a client from getting into a state of mind that would block them from succeeding at a task in therapy. For example, consider a couple that is on the verge of having a constructive dialog. They begin to fall into their characteristic conflict pattern. The man begins to feel rage. Family therapist Virginia Satir might put her maternal hand on his belly and say that she could feel the hurt in his voice. Not only did this interrupt the rage state, but it also primed the husband for vulnerable feelings. This created an opening for dialog, with constructive results.

Would you like more examples? I could go like this all day! Comment, please.

One of my reasons for wanting people to reflect on these techniques, is that much of the American public appears to be adopting the unethical and illogical methods of debating and presenting that they see on TV. As far as I’m concerned, this is one of the signs of the apocalypse (figuratively speaking, of course). Let’s all work to turn this trend around. Educate! Develop compelling ways to highlight and dispense with unethical moves! If anyone should pick up this mantle, I should think it would by psychologically-minded people, because you can see the meta-level communication such as manipulation of implicit memory.

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It turns out in a poll just released by the Kaiser Family Foundation that Congress is doing what Americans are doing: arguing along Party lines over the projected $500B deficit for 2012 and the future of Medicare, Medicaid, Social Security, and the Patient Protection and Affordable Care Act (PPACA). Those who are self-described Democrats prefer to keep or expand existing programs while self-described Republicans would prefer to see repeal with replacement or repeal outright.

So is it any surprise that the Republican-majority House is passing legislation aimed at reducing or repealing these laws, while the Democratic-majority Senate is letting the legislation die in Committee?

If you read through the tracking poll, at the very end of the write-up, you’ll find the interesting tidbit on PPACA:

Since January, the share wanting to expand or keep the law as is has tricked up from 47 to 52 percent, while the share calling for repeal has declined from 43 to 35 percent.

One has to wonder if the President will emerge the tiebreaker between the two, divided chambers, if he can manage to sway public opinion. The President has not underestimated the conflict — the White House website contains pages devoted to infomercial style videos and the Executive has spent money on advertising campaigns, including $3.1M for three commercials for Medicare staring Andy Griffith.

With full implementation of PPACA not due until January 1, 2015, America may see changes yet. There are presidential and congressional elections in 2012, and congressional elections, again, in 2014. Neither the Republican majority in the House, nor the Democratic majority in the Senate should be considered safe.

And about all that is clear at the moment, is that in spite of annual deficits and mounting long-term debt, American health care programs and entitlement benefits are here to stay — at least until the public changes the channel.

References

Kaiser Health Tracking Poll — April 2011. Public Opinion and Survey Research Program

Personal Correspondence between Pamela Gentry and Tegan Millspaw. Department of Health and Human Services. 10/28/2010.

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Ten years ago, the Institute of Medicine and National Research Council published a report entitled From Neurons to Neighborhoods: The Science of Early Childhood Development, in which great emphasis was placed on the need to utilize knowledge about early childhood development to ensure the health and well-being of young children. Many are now taking this further and emphasize what they call “Neuro-Education” – the utilization of scientific findings about learning and environments to create more effective teaching methods and curricula, as well as to influence educational policy.

The lofty goals of Neuro-Education are deeply rooted in the knowledge that genes interact with both early experiences and environments to shape the structure and function of the developing brain. On this topic, neuroscience has been more informative regarding the negative consequences of these interactions in cases where, for example, early experiences and/or environments are less than ideal. For this reason, scientific contributions to policymaking have been focused on interventions in the lives of children facing considerable adversity. However, given the plethora of evidence suggesting that enriching early experiences have beneficial outcomes in terms of cognitive abilities, placing greater emphasis on this facet of policymaking holds considerable promise. In order for neuroscience to influence early childhood education and policy effectively, there must now be a focus on what can be done to increase the impacts of current educational interventions, as well as on how they can best be implemented. To this end, the power of critical periods in brain development, during which time experience has a particularly powerful influence, must be recognized and utilized as part of organized efforts to positively influence the cognitive, emotional, and social development of young children.

It is time for neuroscience to begin to realize its full translational potential in the world of educational policy. Children in the U.S. and beyond are not doing well academically. Arne Duncan, the U.S. Secretary of Education, called the state of education in America a national public health crisis. Importantly, some Neuro-Education initiatives have recently been established in order to begin to address these issues. In 2009, Dr. Thomas J. Carew, Professor of Neurobiology and Behavior at the University of California at Irvine, and then President of the Society for Neuroscience, created the Neuroscience Research in Education Summit, which gave rise to the creation of the Neuro-Education Leadership Coalition that is working to further the goals of Neuro-Education. Also, the Johns Hopkins University School of Education has established a Neuro-Education Initiative, which promotes the applicability of findings from neuroscience to inform and enrich educational practices. In addition, the Harvard Graduate School of Education offers master’s and doctoral degrees in Mind, Brain, and Education, which emphasize the applicability of the biological and cognitive sciences to pedagogy and public policy. Such efforts, however, are only a beginning.

Neuro-Education provides a framework within which science can inform education and public policy through the application of knowledge gained across multiple disciplines that have not traditionally worked in collaboration. If efforts in Neuro-Education are implemented on a large scale, they may help produce children that are better learners who can rise to the challenges required for leadership in the 21st century. Some have even argued that Neuro-Education may be financially and socially rewarding because, if successful, it may result in reduced costs associated with remedial education, clinical treatment, public assistance, and even incarceration. The existence of so many potentially favorable outcomes of Neuro-Education suggests that we, as a society, cannot afford to continue to do without it.

References

Carew TJ, & Magsamen SH (2010). Neuroscience and education: an ideal partnership for producing evidence-based solutions to Guide 21(st) Century Learning. Neuron, 67 (5), 685-8 PMID: 20826300

Shonkoff JP, & Levitt P (2010). Neuroscience and the future of early childhood policy: moving from why to what and how. Neuron, 67 (5), 689-91 PMID: 20826301

Shonkoff JP, & Phillips DA, eds. (2000). From Neurons to Neighborhoods: The Science of Early Childhood Development (Washington, DC: National Academy Press).

Society for Neuroscience (2009). Neuroscience Research in Education Summit: The Promise of Interdisciplinary Partnerships Between Brain Sciences and Education [PDF]

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When the father spoke to my supervisor, his position became clear. His atypical choice was informed by his cultural background and personal character. An immigrant from Eastern Europe, he was adamantly against yielding control of his life to his daughter. He had tried the medicines, and found they sapped his strength and made him weak. He would rather go on strong for as long as possible and remain his own master.

At the hearing, the lawyer told the judge that his client understood his illness and the prospect of oncoming death, and still chose for his own reasons to turn down further treatment. After confirming this with the man himself, the judge denied the daughter’s request, leaving him to live or die on his own terms.

In the aftermath, it occurred to me that there had been no true issue concerning the man’s ability to comprehend the situation or express his feelings. Yet, he was still forced into a court fight because he decided to turn down treatment. Shouldn’t his clearly stated opinions be enough?

Dr. Alec Buchanan of the Yale Department of Psychiatry evaluated the existing state of law and practice concerning informed consent and reported his findings in a paper in the Journal of the Royal Society of Medicine. Examining medical and legal approaches to the issue of capacity in such matters, he found that “mental capacity is not the sole determinant of what will happen when a patient chooses a course of treatment that doctors consider against the patient’s best interests.” Other factors included the views of relatives, “previous expressed views of the patient,” the opinions of medical staff, and the values of society as a whole.

Buchanan pointed out that acceptance of a patient’s medical decision by professionals and family depends in part on the complexity and gravity of the issue. The harder the choice, or the more grave the potential outcome, the higher the level of scrutiny to which any choice will be subjected. Legal opinions have also followed this logic, holding that “the more serious the decision, the greater the capacity required.”

Such scrutiny is in conflict with the value of autonomy, the ability of the individual to act freely in accordance with their own perceptions and belief. Buchanan says that in the context of medical consent, the importance of autonomy increases with the level of a person’s capacity.

While it is clear that these observations correctly describe how the real world works, it is disturbing that they reflect true disrespect of individual autonomy. If it is acceptable to drag clearly lucid people into court to measure their mental capacity for medical consent, why not question capacity for other decisions? The potential outcome of a poorly chosen marriage might be a devastating divorce, with tragic paths for children of the union. A business contract might eventually lead to unforeseen results which could end in someone’s lifetime ruin. Yet we do not find clearly lucid individuals brought into court in advance so they may be judged as to their ability to make those decisions. At most, poor outcomes in domestic or business pursuits might result in a later determination of incompetence.

Of course, in the area of medical treatment, a poor choice may result in permanent injury or death. For this reason, the law permits family, medical staff, and “other interested parties” the option of advance intervention in health care decisions. Such action is a direct negation of the individual’s right to choose in the most crucial and intimate of matters.

How to both assure competence and maintain autonomy?

From the standpoint of the medical profession, the appropriate emphasis should be on ethical and legal education for professionals to assure that the rights of individuals are not violated.

From the standpoint of the patient, there is no substitute for a properly drafted advanced medical directive or power of attorney which clearly sets forth his or her specific desires and which names an individual who can honestly, quickly, and accurately discern a patient’s wishes in the context of medical treatment. Such an individual can sustain the decision of a patient if a question of capacity arises.

The ability of a physician or of the state to override the wishes of a patient and to violate their body should be closely and exhaustively controlled. It should not depend on the subjective assessment of capacity made by someone else, regardless of their qualifications.

Reference

Buchanan, A. (2004). Mental capacity, legal competence and consent to treatment Journal of the Royal Society of Medicine, 97 (9), 415-420 DOI: 10.1258/jrsm.97.9.415

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The BAIPA was initially understood to be antiabortion legislation, granting legal status to all live-born infants in the United States, regardless of whether birth was spontaneous, by Cesarean section, or induced by an elective abortion. Immediately after the passage of the BAIPA, the Neonatal Resuscitation Program Steering Committee issued an opinion that the law should not change neonatology practice with respect to the extremely premature infant. However, the DHS soon released enforcement guidelines that threatened investigations of violations of long-standing regulations — the Emergency Medical Treatment and Labor Act and the Child Abuse Prevention and Treatment Act — if any lay observer claimed that medical care was withheld from a newborn. The enforcement guidelines did not include a stipulation for a physician’s medical training and knowledge to prevail over the layperson’s observations. With the threat of hefty fines and litigation, many physicians and hospitals worry about the day when the BAIPA will actually be enforced.

The last several decades have seen vast improvements in technology and understanding of neonatal physiology, but surprisingly minor improvements in the actual survivability of extremely premature and low birth weight babies. Much debate still surrounds the gestational age and birth weight limits used to identify an infant’s ability to survive outside of the mother’s womb. In most cases, survival of infants born at less than 25 weeks gestation is unlikely. Most practitioners agree that aggressive measures of resuscitation for newborns born at less than 23 weeks gestation is futile and unwarranted. In such cases, neonatologists are more likely to provide comfort care to the infant and the family until the infant dies naturally.

The decision to resuscitate a newborn that is unlikely to survive is a complex one that should involve physicians, other health care professionals, and parents. However, these decisions must also be made quickly. In these cases, timely and appropriate decision-making can decide whether an infant dies, survives with impairment, or survives intact. The consequences of the decisions — positive or negative –- are almost immediate. Medical professionals bring their judgment and experience, as well as perceived obligations and legal mandates to the decision-making; parents bring cultural, personal, ideological, and religious beliefs to the decision-making. Who should be permitted to make the final judgment of what treatment is in the best interest of the child?

The American Academy of Pediatrics recommends that neonatologists perform complete prenatal consultations with parents in the likelihood of an extremely premature birth. Most physicians are comfortable discussing clinical issues with parents, but far fewer are comfortable discussing quality-of-life issues, expected long-term outcomes, or parental preferences. Physicians should provide parents with the medical information necessary for informed decision-making, and but should also foster parental involvement in the care of their child. A framework for newborn resuscitation may be necessary to clarify each practitioner’s role in the care of likely nonviable newborns, and to aid in decision-making, but the government should not be mandating medical procedures or making therapeutic decisions in a complex life or death decision of a child.

References

Campbell, D., & Fleischman, A. (2001). Limits of Viability: Dilemmas, Decisions, and Decision Makers American Journal of Perinatology, 18 (03), 117-128 DOI: 10.1055/s-2001-14530

HUSSAIN, N., & ROSENKRANTZ, T. (2003). Ethical considerations in the management of infants born at extremely low gestational age Seminars in Perinatology, 27 (6), 458-470 DOI: 10.1053/j.semperi.2003.10.005

Partridge, J., Sendowski, M., Drey, E., & Martinez, A. (2009). Resuscitation of Likely Nonviable Newborns: Would Neonatology Practices in California Change if the Born-Alive Infants Protection Act Were Enforced? PEDIATRICS, 123 (4), 1088-1094 DOI: 10.1542/peds.2008-0643

Sayeed, S. (2005). Baby Doe Redux? The Department of Health and Human Services and the Born-Alive Infants Protection Act of 2002: A Cautionary Note on Normative Neonatal Practice PEDIATRICS, 116 (4) DOI: 10.1542/peds.2005-1590

Lakshminrusimha S, Carrion V. Perinatal phsyiology and principles of neotal resuscitation. Clin Ped Emerg Med. 2008;9:131-139.

Bastek, T. (2005). Prenatal Consultation Practices at the Border of Viability: A Regional Survey PEDIATRICS, 116 (2), 407-413 DOI: 10.1542/peds.2004-1427

Partridge, J. (2005). International Comparison of Care for Very Low Birth Weight Infants: Parents’ Perceptions of Counseling and Decision-Making PEDIATRICS, 116 (2) DOI: 10.1542/peds.2004-2274

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The Physician Payments Sunshine Act — a bipartisan piece of legislation introduced by Senators Chuck Grassley (R-Iowa) and Herb Kohl (D-Wisconsin) — was first introduced in 2007, but has failed passage to date. With ever-increasing scrutiny of government and corporate organizations, many expect the amended bill to pass successfully this year. The bill would require drug companies to submit a report to the Secretary of Health and Human Services detailing any payments, gifts, food, trips, samples, rebates, or other type of compensation given to physicians.

While almost no one would argue that transparency in industry — any industry — is bad, and patients and the rest of the public have a right to know for whom their doctors are working, some income should be a private matter. Most professions consider the thought of having the details of all income given or received published on the Internet for general consumption anathema. Plenty of the work carried out by physicians for pharmaceutical companies is legitimate, and the particulars about the amount and quantity of honoraria or compensation are no one’s business except the person completing the work. Many physicians have already declared an end to any work with pharmaceutical companies if the payment details are released. This means that physicians may not be willing to participate in much-needed clinical trials or speak at conferences. These may be unfortunate consequences of a well-intentioned plan.

The line between compensation and bribery becomes blurrier when conflicts of interest are present that affect patient care and professional responsibility. Any financial or proprietary agreement that makes a physician more or less likely to support a particular drug or product than he otherwise would creates an impression of distrust and weakens the medical establishment. Physicians receive support from drug companies in many ways: research support, assistance with manuscript preparation and publication, speaking fees, consulting services, grants, stocks, and many other material items. While many physicians argue vehemently that these arrangements do no harm to patients or the medical profession, and that a drug company can never unduly influence physicians, stacks of literature report otherwise. Not only are physicians, in fact, influenced by these relationships with the pharmaceutical industry, but also these relationships are driving up the cost of health care. For example, one study reports that physicians are many times more likely to prescribe a particular drug after meetings with drug company representatives or participation in conferences sponsored by the industry, even if that drug was not the best-choice agent. When newer, often more expensive agents, are prescribed, the costs to the patient and the insurance carriers increase unnecessarily.

Safeguarding the public is paramount in today’s medical climate. Change is likely coming to the organization and structure of the American health care model, and the public is paying more attention to conflicts created by inappropriate relationships between physicians and drug companies. Americans spend approximately $200 billion annually on prescription drugs, and this is the fastest growing piece of the health care budget. Patients want to make sure that this money is being used appropriately and for the right reasons.

Make no mistake: the pharmaceutical industry is not all bad. Certainly, modern medicine would not be where it is today were it not for the innovative research and development of the drugs and devices made possible by private pharmaceutical companies. Drug companies do provide low- and no-cost drugs to uninsured and indigent patients and do help fund professional meetings and medical journals that provide current and candid information. But, the industry is a for-profit business whose sole purpose is to make money. Like any for-profit company, the pharmaceutical industry seeks profits through wise investments. The investments, in this case, are relationships with physicians.

Why do physicians engage in relationships that some deem, at the very least, questionable? Many are motivated by entitlement. One study reported that, despite strong efforts of medical schools to discourage gift taking from pharmaceutical companies, an overwhelming majority of medical students felt entitled to these gifts. Even those that reported being troubled by the gifts accepted them. Recognition and belonging motivates other physicians to accept the largesse offered by the drug industry. It is undeniably desirable to be recognized as an expert, or at least invited to a fancy steak dinner to mingle with colleagues. And, in this day of decreased reimbursement and increasing costs of medical education and business ownership, money is an irrefutable, and understandable, motivator for many physicians.

Many academic medical centers and professional organizations, including the American Medical Association, support the new federal legislation and have previously renounced the idea of industry handouts. Gifts — in any form — from the pharmaceutical industry to physicians have the potential to compromise the objectivity of treatment decisions, increase the costs of health care, and erode the trust of the patient-physician relationship. While federal legislation disclosing financial details of these relationships may not be the answer, physicians need to carefully examine their own relationships with the pharmaceutical industry and consider the implications on their professional relationships.

References

Kondro, W. (2008). Pharma giants to create databases on gifts to physicians Canadian Medical Association Journal, 179 (11), 1118-1118 DOI: 10.1503/cmaj.081669

LICHTER, P. (2008). Debunking Myths in Physician–Industry Conflicts of Interest American Journal of Ophthalmology, 146 (2), 159-171 DOI: 10.1016/j.ajo.2008.04.007

MARCO, C., MOSKOP, J., SOLOMON, R., GEIDERMAN, J., & LARKIN, G. (2006). Gifts to Physicians from the Pharmaceutical Industry: An Ethical Analysis Annals of Emergency Medicine, 48 (5), 513-521 DOI: 10.1016/j.annemergmed.2005.12.013

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As Election Day draws near, I imagine that both McCain and Obama are exhausted; both have been run through the ringer. After all, they must endure non-stop campaigning schedules, high pressure debates, and the constant scrutiny of the press. Along with this, every aspect of their lives are being examined under the most powerful of microscopes. From tax records to religious affiliations to personal friendships, both men are left bare, no secrets uncovered.

This openness extends to their health histories as well. Both candidates issued records or statements detailing major health issues. Not surprisingly, Obama, 25 years younger than McCain, has a clean bill of health; the only exception is his difficulty kicking the smoking habit.

McCain’s record is fairly impressive as well even though he is 72. Along with his past problems with melanoma he may need joint replacement therapy down the road, a result of his time spent as a Prisoner of War (POW). Along with this, his records note that he tried to hang himself, eight months into his 5+ years spent as a POW. He was found to be mentally stable after being examined for mental disorders and we can assume that his suicide attempt was a rational decision considering the circumstances he was in.

Initially I was surprised upon reading this. After all, McCain’s strength of character, proven by his perseverance during his POW days as well as through other reports from those who know him well, seems to be contrary to this act of desperation. Don’t get me wrong, I don’t fault McCain because of this; he is a human susceptible to human weaknesses and certainly he was in the midst of more devastation and pain than many of us can imagine. This image just didn’t concur with the fiery candidate that I see on TV.

But eventually my surprise over his health details gave way to curiosity. Today he still suffers from ailments related to his time spent representing our country. This coincides with the reports that McCain’s patriotism and dedication to his country is intense. And it seems as if this would go a long way towards drawing voters. After all, for a future president, what speaks louder than loving your country so much that you are willing to suffer intensely?

Well, quite a bit it seems.

Most polls show McCain trailing Obama by a substantial margin. It seems that there is something more important to people than patriotism, the good old-fashioned War World II Generation-goodness. Don’t get me wrong, I do not doubt Obama’s patriotism but McCain’s past is textbook-flag-waving-country-first-stuff.

What is it that Americans value more highly than what McCain offers? Obama’s calmer and steadier demeanor? Liberal views? A change in ranks? Do our changing values represent progress? I don’t know.

But what I do know is that McCain’s type of patriotism may be dying. Excluding the military, you seldom hear young people talk about their country in endearing terms. And you certainly don’t see many who feel so strongly for their country that they are willing to put country above all else.

Obama may be the face of the future but for the sake of our country, I hope that McCain’s brand of patriotism isn’t a thing of the past.

Reference

F. Charatan (2008). Records of presidential candidates show McCain has had melanoma and Obama is using nicotine replacement therapy BMJ, 337 (oct27 2) DOI: 10.1136/bmj.a2260

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Since the debate Obama’s running mate, Joe Biden, responded to McCain’s implications with, “If it walks like a duck, if it looks like a duck and it quacks like a duck, it’s a duck!”

But regardless of the promises or perceived merits of either candidate, no one really knows what a McCain or an Obama country would look like. We listen to their words, review their records, and seek out the truth but as to the reality of their campaign promises, it’s anybody’s guess. And as to Biden’s duck analogy… well, it’s a possibility but not a guarantee.

Still though, McCain’s ties to the conservative voter base rattles me somewhat. Not that I’m against his views particularly but I worry about the attitude that seems to be prevalent among some republican supporters. In extreme cases, there seems to be an undercurrent of intolerance, sometimes to the point of crazed hatred. When your supporters yell, “Kill him,” that’s taking campaigning too far. It makes me wonder if the Republican base is healthy? Are common sensibilities and the ability to be un-objective when necessary less prevalent among this group?

I direct this question to republicans instead of democrats for two reasons. One, mentioned above, has to do with the dangerously frenzied sort of atmosphere that has been reported at republican rallies. And my second reason has to do with Bush, the current republican president. It seems that the Bush administration hasn’t exercised common sensibilities regarding health issues. In a BMJ article, Douglas Kamerow points out that over the last eight years this administration has made choices in regards to health issues and policies that seems to shrug off scientific knowledge in favor of personal views and interests. It seems that many times Bush was “an army of one” when dealing with hot-button and high-profile issues — refusing to use science as a basis for decisions and doing… well, what he (or his administration) just wanted to do. The Union of Concerned Scientist has documented many of these instances including:

• Insisting on and publicizing the effectiveness of abstinence only sex education, despite a lack of evidence for it.
• Censoring testimony before Congress by the Centers for Disease Control and Prevention (CDC) on the health hazards of climate change.
• Posting erroneous data linking abortion and breast cancer on CDC’s website.
• Distorting evidence on the effectiveness of condoms in preventing HIV transmission and prevention
• “Stacking” a federal advisory committee on prevention of lead poisoning to prevent more stringent standards.
• Adding non-scientific proponents of positions favored by the administration to sessions at scientific meetings in the guise of providing “balance.”

Along with these actions, this administration directly influenced other key issues by refusing to publish evidence, allowing invalid data to influence decisions, and changing test results. Even more disturbing is that this administration, “…prevented its own surgeon general from speaking out on topics in the areas of mental health, global health, and secondhand smoking.” In other words our health policies have been based, at least partly, on a very biased and self-serving administration.

Is this pattern related to the republican’s large evangelical christian voter base? Possibly knowing that many of your constituents agree with the outcome, if not the means, may have allowed Bush to endorse these methods. But I am going to venture to say that most members of this subgroup would not sanction these unethical methods. Most rational opponents of say, sex education or abortion would not want misinformation to lead the argument for policy changes. Logical arguments that are not based in science exist for every issue so there is no need to distort scientific results; this only leads to more governmental distrust and is misguided.

Both ideologies, support bases, and candidates have taken on a life of their own by this point in the race. Will McCain’s views cause him to do the same as his party’s predecessor? Could Obama push his views or his constituent’s views via this same avenue? I hope not. An intolerance to science is dangerous for everyone — regardless of party ties.

Reference

D. Kamerow (2008). Politics and science: a cautionary tale for the presidential candidates BMJ, 337 (oct14 4) DOI: 10.1136/bmj.a2093

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The ADA opens up wonderful opportunities for people wanting to pursue their careers even after a severe medical condition. It also has several guidelines for accessibility of the community — from specifications of the height of water fountains and sinks to measurements on width of doorways and hallways. These regulations allow easy maneuvering of wheelchairs and other equipment, making the community completely accessible to everyone without discrimination.

It is extremely heartening to see children and adults with disabilities benefiting from these legal guidelines. Because of such regulations, families can attend local community events, travel, and even take long vacations together. Granted, it takes some additional planning and effort, but at least they have the option. Not all countries are so accessible or inviting to persons with disabilities. In some countries, a disability pretty much means the end of life as one knew it.

The terms “disability” and “handicap” take on a much more literal and ominous meaning in developing nations. A young boy with a complete spinal cord injury in the cervical area will be confined to bed; unless carried by his family member or an aide. An elderly gentleman with a stroke will remain restricted to mobility within his apartment because he cannot navigate stairs, and his multi-storey apartment does not have an elevator. The concept of wheelchairs is a luxury — available only to the really affluent who can afford to have equipment custom built or imported from other countries. Corrective bracing and artificial limbs for persons with muscle imbalance or amputations is available, but very rarely used effectively. This is due to many factors like cost, lack of awareness, poor education and social stigma.

One hopes that the trend will gradually change. More businesses in the USA are taking ownership for issues around the world. Some companies that manufacture limb prosthetics and braces work closely with patients and their families. They collect old braces that patients have outgrown and donate them to countries that require them. Other companies offer financial support to smaller businesses in poorer nations. The World Health Organization (WHO) also funds educational programs that spread awareness about issues such as these. They even provide specific training programs for bracing and prosthetics.

All of this will lead to a more global solution to the effects of disability and loss of function.

Online Resources

The Americans with Disabilities Act.

The World Health Organization.

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Should the government mandate a health care plan or should insurance carriers do a better job of providing coverage?

The Democrats, led by Presidential candidate Senator Barack Obama, plan to rely on a “play or pay” system that would improve access to insurance and move the United States toward universal coverage. This system builds on the predominating employer-sponsored insurance coverage that has been a cornerstone of the American workforce since the 1940’s. Under the Democrat’s plan — which is a resurgence of the plan of choice for many Democrats in the 1990’s — employers would be required to offer employees insurance coverage or pay a tax.

This plan would retain private insurers, but would heavily regulate the industry to ensure that all Americans had access to coverage. Provisions are in place to allow currently insured Americans to keep their current coverage, if they so choose. Under Obama’s plan, Americans without access to other group coverage could either choose a new government health care plan that would be similar to Medicare, or choose a private insurance option from a national health insurance exchange.

Obama also plans to establish purchasing pools for businesses to increase access to coverage, provide subsidies to low-income families for the purchase of health insurance, and expand current government programs, like Medicaid and the State Children’s Health Insurance Program to cover more low-income Americans. Further, regulations would be in place to prevent insurance companies from denying coverage for pre-existing conditions or charging high premiums to sicker individuals.

The impact that Obama’s plan might have on coverage is impossible to assess. It depends on the extent of subsidies offered, prices of premiums, and total payroll tax offered to employers. For example, if the employer’s tax is set too low, many employers would likely choose to pay it rather than continuing to offer coverage, and enrollment in a national plan could be substantial – substantial enough that the funds may not exist.

Also, like McCain’s plan, Obama’s plan may not cover all of the uninsured Americans today. The Republican’s plan offers no mandates for coverage, but the Democrats do mandate coverage for children. With no mandate on adult health care, many uninsured adults could remain without health insurance. (Obama has not ruled out a mandate for adults in the future if the plan does not lead to universal coverage.)

The Democrats plan to finance this new health care system by repealing tax cuts adopted by the Bush administration for families making more than $250,000 annually. (Interestingly, the Congressional Budget Office already plans on these tax cuts expiring in 2010, so their expiration may not generate the necessary $50 to $65 billion to finance the program.) The tax paid by employers who do not offer coverage would also help fund government coverage.

Like the Republican plan, the Democrats also plan to control costs by encouraging the use of electronic medical records, promoting disease management, emphasizing prevention and public health, and paying providers based on health outcomes. All of these are certainly laudable goals for either side of the political aisle, but it is unlikely that any of these measures will significantly reduce costs in the short run.

Senator John McCain and the Republicans support a system of free markets and deregulation, while Senator Barack Obama and the Democrats support employer mandates and new regulation as a means of reforming our broken health care system and expanding access to health coverage. Both of the candidates promote a platform of health care reform, but there are certainly no guarantees that any reform will come about in a timely fashion. Even if he can incite reform, the likelihood of a new system looking anything like either of these two plans is remote. Both plans still leave behind uninsured Americans and lack significant funding sources. Change is coming, but which change is best for all Americans?

References

J. Oberlander (2007). Presidential Politics and the Resurgence of Health Care Reform New England Journal of Medicine, 357 (21), 2101-2104 DOI: 10.1056/NEJMp078202

J. Oberlander (2008). The Partisan Divide — The McCain and Obama Plans for U.S. Health Care Reform New England Journal of Medicine, 359 (8), 781-784 DOI: 10.1056/NEJMp0804659

R. Steinbrook (2007). Election 2008 — Campaign Contributions, Lobbying, and the U.S. Health Sector New England Journal of Medicine, 357 (8), 736-739 DOI: 10.1056/NEJMp078151

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Health care reform is an important issue of the 2008 Presidential election, and both Republicans and Democrats are proposing radical changes that will change the face of health care delivery in this country. Both sides of the political aisle aim to make health care more affordable and control escalating costs. Both Republicans and Democrats also plan for employers having a smaller role in medical benefits. The differences in how each side wants to achieve these goals are striking, however.

The Republican plan, lead by Presidential nominee Senator John McCain, creates a national insurance market that gives consumers more power and choice than we currently have. McCain plans on eliminating the tax break given to employees if their employer provides health care. This tax exclusion dates back to the 1940’s and originally allowed employers to compete for workers by offering tax-free benefits instead of higher salaries. This also allowed employers to provide better benefit packages than employees could buy with their own after-tax dollars.

Under McCain’s plan, benefits would be taxed as income, generating nearly $3.6 trillion in government revenue over 10 years. However, he proposes a $2500 tax rebate for individuals, $5000 for families, to compensate for the increased tax burden. This is a more equitable allocation of resources, as each American — employed or unemployed — receives the same tax rebate under the new plan, while the tax exclusion now in place is based on the employee’s tax bracket. On the other hand, while employees would now be able to buy the same benefit packages as employers, the incentive for employers to provide coverage would come to an end. Some experts believe that under McCain’s plan, employers would stop paying for heath care within 3 to 4 years.

Without employer-provided coverage, individuals could choose a plan that better meets their needs, age, health status, and stage of life. McCain’s plan deregulates insurance markets and encourages competition. He would allow people to purchase insurance plans across state lines, enabling us to shop for lower-cost, more comprehensive plans that suit each person or family’s needs.

John McCain also plans to change the way Medicare receives payment for services. Rather than fee-for-service reimbursement, he proposes payment for episodes of care, and payments based on outcomes. These changes would encourage broader reform in the health care system and promote accountability among health care providers.

Further, John McCain plans to speed up generic drug development, encourage prevention in health care and the management of chronic diseases, adopt malpractice reform, and enhance the use of health information technology. However, under McCain’s plan, most uninsured Americans would remain uninsured. The high prices of health insurance, even with a tax rebate, may be unaffordable to low-income workers, especially if employers discontinue providing benefits. To improve access to coverage, McCain proposes a “guaranteed access plan” to create insurance alternatives for people still unable to afford or obtain health care. Currently, 34 states operate similar plans for medically uninsurable residents. Sadly, these plans encounter high costs, limited benefits, and exclusions for pre-existing conditions and offer no real relief from commercial insurance plans.

The Republican’s health care reform package is far from perfect, but is an interesting comment on the Republican’s view of free markets. This plan aims to treat health care as a resource, not an entitlement, and encourage nationwide competition. The Republicans believe that an important step in controlling health care costs is to treat Americans, not just as patients, but also as consumers.

In health care and politics: The Democrats, we will examine the health care reform plan of Barack Obama and the Democrats.

References

J. Oberlander (2007). Presidential Politics and the Resurgence of Health Care Reform New England Journal of Medicine, 357 (21), 2101-2104 DOI: 10.1056/NEJMp078202

J. Oberlander (2008). The Partisan Divide — The McCain and Obama Plans for U.S. Health Care Reform New England Journal of Medicine, 359 (8), 781-784 DOI: 10.1056/NEJMp0804659

R. Steinbrook (2007). Election 2008 — Campaign Contributions, Lobbying, and the U.S. Health Sector New England Journal of Medicine, 357 (8), 736-739 DOI: 10.1056/NEJMp078151

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In 2006, the military outlawed harsh interrogation techniques such as waterboarding, hooding, and using military dogs. However, detainees can be kept in complete isolation for up to 30 days, which could result in post-traumatic stress. Some military psychiatrists and psychologists have been involved in teaching specific psychological concepts, such as learned helplessness, to military personnel. Physicians and psychologists do have a responsibility, not only ethically, but also mandated by the military to report inappropriate and coercive interrogations to the proper authorities. However, that means that the physicians have to be involved on some level in the interrogation, even if it only viewing it, which goes against the issued statements by the APA and AMA.

Some military psychologists have argued that they should be involved to make sure that the detainees and prisoners are treated well. In other words, they feel that if they were not there to supervise, the interrogations of the prisoners would be harsher than necessary. However, this position goes against what the professional organizations recommend. This leaves some military physicians and psychologists in a bind; on one hand they feel morally obligated to monitor the well-being of detainees but on the other hand, it is unethical for them to do so.

Many physicians believe that treating prisoners well, being kind to them is much more effective than harsh interrogation or even other more mild but aversive interrogation techniques. There is evidence so support that belief. Information given when under duress is often unreliable; social psychologists have been studying a related topic –- eyewitness testimony –- for a number of years. They have found that individuals under a lot of stress, such as having a gun pointed at them, are much more unreliable than outside observers. So, there is considerable theoretical evidence that treating prisoners as humanely as possible both inside and outside interrogations leads to the most reliable information.

Should medical and health care professionals be directly or indirectly involved in interrogation? If so, what should their roles be? If not, why shouldn’t they be involved? Do you agree with the position of the APA and AMA? Should physicians and psychologists even be involved in the general training of military interrogators?

Reference

J. H. Marks, M. G. Bloche (2008). The Ethics of Interrogation — The U.S. Military’s Ongoing Use of Psychiatrists New England Journal of Medicine, 359 (11), 1090-1092 DOI: 10.1056/NEJMp0806689

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BMJ’s article, New York’s road to health, quickly brought to mind one of those sayings in just two simple words:

Money Talks

If you’ll allow me to though, I’m going to add three words to this saying to make it even more apropos for this topic:

Across the Board Money Talks

In Karen McColl’s feature story, New York’s daring health initiatives are summarized with an emphasis on the role that current New York City mayor, Michael Bloomberg, plays in these events.

New York City has plenty to boast about when it comes to health mandates that have successfully been put in place: the Smoke Free Air Act, the phasing out of trans fatty acids from many restaurants, and requiring certain restaurant menu items to list calorie information. But the most recent health initiative is the one that I found surprising.

As part of a pilot project, selected low-income families can earn money for taking care of themselves and their families. How much money?

• Maintaining subsidized health insurance — $20 per parent group, $20 for all children
• Keeping up private or employer insurance for the entire family — $50/month
• Attending an annual medical check-up — $200 per family member
• Attending suggested follow-up visits within the correct timeframe — $100 per family member
• Attending regular preventive dental check-ups — $100 per family member

It is suggested that Mayor Bloomberg’s unique leadership and personal qualities are largely responsible for enabling New York City to make such huge and powerful public health gains. Not only is he highly dedicated to public health in general, he has money.

Bloomberg is a private philanthropist who donates vast amounts of money to health causes. Plus, his connections and personal monetary strength means that he has a wide breadth of influence.

I’m not suggesting that the city’s success hinges upon Bloomberg’s wealth. In fact, Dr. Frieden, the health commissioner doesn’t mince words. He states:

None of these things would have been possible without [Mayor Bloomberg's] leadership. It took a lot of political effort to get these things through, and it involved taking a lot of political heat to do the right thing. They are all now very popular, but getting them through meant standing up to vested interests and doing things that lead to a fairly brutal critique in the tabloid newspapers. And Mayor Bloomberg was willing to do that because he knew that it would save lives.

The barriers that prevent disadvantaged families from taking care of their health are beyond the scoop of this article but I am optimistic that this plan will work because money is behind the initiatives. From both the man who is the “face” of the program to the money provided to the families who follow the requirements, money is involved. And money talks.

Reference

McColl, K. (2008). New York’s road to health. BMJ, 337(jul08 3), a673-a673. DOI: 10.1136/bmj.a673

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