Health and Disability

We know that as the energy in the health care world turns to reinventing health care delivery systems, social and economic determinants of health and the role they play in community health are front and center. Studies have uniformly shown that social, economic, environmental and behavioral factors play a larger role in determining health than genetics and health care combined (as illustrated by the County Health Rankings and Roadmaps program infographic below).

However, we know that addressing any of the social and economic determinants of health requires robust partnerships between health care systems and providers, as well as numerous others in the community, many of whom may have never worked together in a formal way. The intersection between health and human services and housing is well-documented by the Kresge Foundation and Policy Link in their Healthy Communities of Opportunity: An Equity Blueprint to Address America’s Housing Challenges

In August 2015, Turing Pharmaceuticals and its then-chief executive, Martin Shkreli, purchased a drug called Daraprim and immediately raised its price more than 5,000 percent. Within days, Turing contacted Patient Services Inc., or PSI, a charity that helps people meet the insurance copayments on costly drugs. Turing wanted PSI to create a fund for patients with toxoplasmosis, a parasitic infection that is most often treated with Daraprim.

Having just made Daraprim much more costly, Turing was now offering to make it more affordable. But this is not a feel-good story. It’s a story about why expensive drugs keep getting more expensive, and how U.S. taxpayers support a billion-dollar system in which charitable giving is, in effect, a very profitable form of investing for drug companies—one that may also be tax-deductible.

New research suggests delayed treatment for concussion could prolong recovery.

Many college athletes, however, don't immediately recognize or report concussion symptoms, the study of nearly 100 players found. And compared to head-injured athletes who were evaluated right away, those who put off reporting symptoms were sidelined about five days longer on average.

"If you are an athlete and you are experiencing concussion symptoms, you should immediately engage your athletic trainer or team physician so that you can be evaluated," said the study's lead author, Breton Asken.

"Our findings indicate that ... will give you the best chance to return to your sport more quickly," said Asken, a graduate student in the clinical psychology program at the University of Florida.

Retails clinics emerged over 15 years ago to solve a basic, intractable problem — how to make routine primary care services convenient and accessible. With increasing demand for primary care, a high and swelling rank of uninsured, and a low-margin, nine-to-five business model, the industry was primed for a new mode of delivering care.

This model of low-cost, routine primary care services after-hours in settings that most Americans could readily access has proven popular with consumers. There are now more than 1,800 retail clinics across the country, delivering a growing array of primary care services to millions of people. With virtually unfettered access to routine primary care services, one might expect that excess utilization would be generated.

As a fixture of the health care system, critical questions are rightly being asked regarding the impact that retail clinics are having on cost, access, and quality. While researchers in the Ashwood study who used claims from Aetna pointed out that they could not assess impact on total cost of care given lack of hospital and pharmacy claims in their analysis, they did find that 58 percent of retail clinic cases represented new utilization, with an associated $14 per person per year net increase in spending.

It is important to point out that the analysis did not include uninsured individuals or Medicaid beneficiaries, who are less likely to have a usual source of care or less able to access that care during regular business hours. For these individuals the retail clinic may be a much needed access point, enabling new utilization that at least the individual thinks is necessary and additional data may provide necessary by any standard.

Penicillin is now available in copious amounts, as are other bacteria-killing antibiotics. A thorn scratch today seems a minor irritant, not a potential killer. But that may be too sanguine. A study by America’s Centres for Disease Control (CDC) found that the number of cases of sepsis rose from 621,000 to 1,141,00 between 2000 and 2008, with deaths rising from 154,000 to 207,000. One reason for that is the emergence of MRSA (pictured being attacked by a white blood cell)—a variety of Staphylococcus aureus that cannot be killed with methicillin, one of penicillin’s most effective descendants. This could just be a taste of things to come. Three years ago the CDC produced a list of 18 antibiotic-resistant microbes that threaten the health of Americans (see table). Five of them (including MRSA) cause sepsis.

Such worsenings would not be restricted to hospitals. “Multi-drug resistant” and “extensively drug resistant” strains of tuberculosis cause 200,000 deaths a year, mostly in poor countries. Most people who die of tuberculosis at the moment do not die of one of these strains. But they are responsible for more than an eighth of fatal cases, and those cases might otherwise be susceptible to treatment.  

Neisseria gonorrhoeae is another bug that has repeatedly developed resistance to antibiotics. When penicillin was first introduced it worked very well against gonorrhoea. When its effectiveness began to fall, it was replaced by tetracyclines. Those gave way to fluoroquinolones, and those, in turn, to cephalosporins. Now, some strains can be tackled only with a combination of ceftriaxone, a cephalosporin, and azythromicin, an azalide. There is nothing else in the locker.

If worries about microbial resistance are cast wider to include not just antibiotics (which attack bacteria) but drugs against parasites, like malaria, and viruses, like HIV, the problem multiplies, particularly in poor countries. 

The study, published this week in Nature Communication, confirmed that dementia rates have been falling—by an average of around 20% over a 20-year period. But the average masks are a more interesting trend: the reduction was predominantly observed in men.

In the 1990s, for every 1,000 men aged 70-74, 12.9 developed dementia within a year. Twenty years later, that figure dropped to 8.7. The reduction was even more dramatic for men aged 65-69, as the relative number of new dementia cases more than halved over the same period.

The older we get, the more likely our circadian rhythms are disrupted. For example, blood pressure (BP), not only tends to increase but as well become more irregular. Luckily, as we show in our research, melatonin helps to ameliorate both trends.

63 senior respondents of a mean age of 80 were studied during 3 consecutive weeks. First week control data were collected for 7 successive days. Over the next 2 weeks, the seniors were administered a low dose of melatonin (1.5 mg) each day by night at 10:30 p.m. On the third week data were monitored again.

Melatonin significantly reduced BP. The hypotensive effect was dependent on time. The maximum systolic BP lowering effect of melatonin falls between 3:00 and 8:00 in the morning, the time of the highest risk of heart attacks and strokes. Nighttime and morning BP decreased more profoundly on average -8/3.5 mm Hg for SBP/DBP, respectively.

Moreover, the higher the mean systolic BP was during the first week, the more it dropped on the second week of melatonin administration. Melatonin also decreased the overall variability in BP.

Melatonin ws effective in synchronizing disrupted circadian rhythms of BP, heart rate and body temperature, making these circadian rhythms smoother and less irregular. None of these effects was found in 34 placebo treated seniors, thus ruling out the possibility that rhythms could be improved just because of regular schedule and presence of medical personal who took measurements.

On May 13, the Office of Civil Rights (OCR) of the Department of Health and Human Services (HHS) issued a final rule implementing section 1557 of the Affordable Care Act. The rule finalizes a proposed version issued in September of 2015, analyzed in this blog at that time. The final rule was accompaniedby a press release, summary, and series of fact sheets.

Section 1557 of the ACA provides that an individual shall not, on the basis of race, color, national origin, sex, age, or disability, be

• excluded from participation in,
• denied the benefits of, or
• subjected to discrimination under

any health program or activity of which any part receives federal financial assistance, or any program or activity that is administered by an agency of the federal government or any entity established under Title I of the ACA (the private insurance reform and affordability title). The prohibited grounds for discrimination are specified by Title VI of the Civil Rights Act of 1964 (Title VI) (race, color, national origin), Title IX of the Education Amendments of 1972 (Title IX) (sex), the Age Discrimination Act of 1975 (Age Act) (age), and Section 504 of the Rehabilitation Act of 1973 (Section 504) (disability). Section 1557 does not apply to discrimination based on religion.

Long-term care grew more expensive again this year, with the cost of the priciest option, a private nursing home room, edging closer to $100,000 annually, according to a survey from Genworth Financial.

Americans also are paying more for other care options like home health aides and assisted living communities, while adult day care costs fell slightly compared to 2015, Genworth reported in a study released Tuesday.

Private nursing home rooms now come with a median annual bill of $92,378, an increase of 1.2 percent from last year and nearly 19 percent since 2011. That’s roughly twice the rate of overall inflation and breaks down to a monthly bill of $7,698.

Coverage costs also are rising, and many people don’t understand these expenses until they face them, said Joe Caldwell of the National Council on Aging, which is not connected with the study.

“It’s really becoming more and more difficult for the average family ... to even purchase long-term care insurance,” said Caldwell, the nonprofit’s director of long-term services and support policy.

Medicare doesn’t cover long-term stays, so a large swath of people who need that coverage wind up spending down their assets until they qualify for the government’s health insurance program for the poor, Medicaid.