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The CMG Voice

Colorado takes action to cap insulin co-pays

Posted Wednesday, June 26, 2019 by Carl-Erich Kruse

Recently Colorado Governor Jared Polis signed a bill capping insulin co-pays at $100 per month. Colorado is the first state to tackle the ballooning cost of insulin; it may have just set the route for other states to follow.

Insulin therapy was first used nearly a century ago, and first synthesized more than sixty years ago. Yet, the price of insulin increases at a seemingly increased rate. What, outside of the healthcare industry, has seen an eight-fold price increase since 2004? A vast majority of the worldwide insulin is generated by three giant pharmaceuticals: Sanofi, Eli Lilly, and Novo Nordisk. Competition, it seems, has not led to lower drug prices. While everyone – manufacturers, insurance companies, regulators, the patent office - seems to be pointing fingers at each other, more and more money flows out of consumers paychecks.

Colorado is in a position to take this action because each state regulates its insurance market. The Colorado law provides that monthly insulin co-pays cannot exceed $100, regardless of how much insulin the patient uses. Anything beyond that $100 will be paid by insurance companies, according to the law.

It is evident to nearly anyone touching healthcare that the cost of care is stretching Americans to their limits. We made many of the same complaints a decade ago, but we have seen prices continue to increase at accelerated rates.

In addition to the price cap, the new law directs the Attorney General to investigate and issue a report on why manufacturers have rapidly increased the price of insulin in recent years.

Read coverage of the new law in the Denver Post here.

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Egg consumption is not related to stroke incidence

Posted Thursday, June 20, 2019 by Carl-Erich Kruse

The debate has raged for seemingly a generation regarding the healthfulness of eggs. Google “eggs and diet” and you’ll see “about 342,000,000 results.” Add to the mix a study published recently in the American Journal of Clinical Nutrition revealed a surprising finding: neither egg nor dietary cholesterol intake was associated with higher incidence of stroke.

The study started in 1984-1989 with baseline examinations of 1950 men aged between 42 and 60. The men’s dietary intakes were assessed and the data for the apoE phenotype (a marker indicating greater susceptibility to effects of cholesterol) was available for slightly more than half the men. The incidence of stroke was then recorded over the follow-up period (21.2 +/-7.2 years). The rate of consumption of eggs and dietary cholesterol varied among the study group, but the incidence of stroke, either ischemic or hemorrhagic, did not correlate with these rates. Even when accounting for the apoE phenotype.

The study demonstrates in part that concern about one or another element of our diets is not meant to apply universally. It is really worth stepping past the hype of the headlines to make our own individual lifestyle and health choices, inasmuch of a capacity as we can.

Lewis Black may have best expressed the frustration between competing theories of eggs and health; or he may have just been the funniest. Armed as we are with evidence of benefits and drawbacks of eggs in our diet, our best and healthiest option continues to be to simply navigate our own health interests so they remain compatible with our diet. I for one am already looking forward to breakfast tomorrow.

Read the study here.

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No Single Solution to America’s Abysmal Maternal Mortality Rates

Posted Friday, June 7, 2019 by Carl-Erich Kruse

Readers of this blog may have read prior coverage of maternal mortality rates in the United States. The Centers for Disease Control recently released the results of a multi-year study of pregnancy related maternal deaths in the United States. Over the course of the study period, 2011-2017, about 700 women died per year in the United States from childbirth related complications. A break down of the results paints a distressing picture for expectant mothers and their loved ones.

The CDC found that some sixty percent of these deaths were preventable with proper medical care.

Additionally, African-American and Native women died at a rate 3.3 and 2.5 times that of white women. Why these extreme disparities exist is the subject of further research and coverage, but one theory regards the quality of care available to different communities in the United States.

Why are some four hundred women dying each year from preventable complications? Why, frankly, may be too big a question to tackle. In each specific case that was preventable, though, there was miscommunication, omission, lack of sufficient access, or overlooking warning signs. The CDC report suggested that reducing the rate of pregnancy related deaths has to be a multi-pronged approach by “reviewing and learning from each death, improving women’s health, and reducing social inequities across the life span, as well as ensuring quality care for pregnant and postpartum women.” Some suggestions included patients and providers working together to best manage chronic health conditions and standardizing approaches to handling obstetrics emergencies.

The process of improving healthcare for expectant mothers is an ongoing and evolving process. Reports like this one, from the CDC no less, serve to provide background for systemic improvements to patient care by raising discreet issues of public interest. There is no silver bullet to improving outcomes for these patients, and change is slow, but studies like this demonstrate that change must happen. The test now is: how does the healthcare system, how to OBs, how do facilities, improve their systems, how do we provide more care to expectant mothers so that we may reduce our maternal mortality rates to be consistent with the rest of the developed world?

Of the many possible answers, bringing meritorious civil suits alleging wrongful death are a useful way to effect change. When community members form a jury and decide what the standards should be in such circumstances, there will be a future deterrent effect, and all of us will be safer.

Read the CDC report here.

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Medical Bills that can Bite

Posted Thursday, May 30, 2019 by Carl-Erich Kruse

It’s a parents worst nightmare (part 1): Josh Perry and Shelli Yoder received a call in the middle of the night that their daughter, away at summer camp, had been bitten by a copperhead snake. She was being transported via air ambulance to a hospital from the remote wooded location. Josh and Shelli launched out of bed to race her to the hospital.

It’s a parents worst nightmare (part 2): Josh and Perry received medical bills some weeks later for their daughter’s treatment: $142,938.

The bill was not for a lengthy hospital stay, not for dozens of medication administrations, not for interventional procedures. The air ambulance was $55,577.64; the Emergency Room was $3,851. Amazingly, the antivenin, four vials worth, cost $67,957. That’s $16,989.25 per vial.

How did it get to cost so much? And who bears this cost?

Kaiser Health News reports that the manufacturer of this antivenin has a virtual monopoly in the US. The manufacturer, CroFab, charges $3,198 per vial. Some of you have already figured out that is a $13,791.25 difference. A portion of the cost was then negotiated down by the family’s health insurance, which paid $107,863.33. Although the family did not pay anything out of pocket, these often extravagant costs for medication frequently end being absorbed by rising premiums or by Medicare/Medicaid. In effect, we all pay.

Efforts are under way to manage health care costs. Recent federal law requires hospitals to post prices online. Perhaps coincidentally, the hospital in this story now charges $5,096.76 for this antivenin. Competition may be helping too: other antivenin products are arriving on the market for approximately 1/3 of the price.

As multiple efforts grow and evolve to manage drug prices, stories like these will (hopefully) become less commonplace.

Read the Kaiser Health News article here.

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Feres Doctrine Anything but Fair to Servicemembers

Posted Monday, May 27, 2019 by Tyler Goldberg-Hoss

On this Memorial Day, it is obvious that we take time to remember and honor those men and women who have died while protecting our country.

It is also a good time to reflect on a law which continues to single out these same men and women for unfair treatment when they are injured as a result of the negligence of other enlisted personnel. This law is called the Feres Doctrine, and it needs to be changed.

The Doctrine was created in part to avoid litigating military decisions in civilian courts. However, in practice it prevents much more than that. In the context of medical care, it prevents patients from bringing claims of medical negligence involving care at Naval Hospitals such as the one in Bremerton.

We have written about the Feres Doctrine nearly three years ago in the context of the case of Rebekah Daniel.

Ms. Daniel was active duty when she delivered a healthy daughter at the Naval Hospital. Unfortunately, doctors allegedly failed to stop her from bleeding, and she died.

A local attorney attempted to bring her claim, knowing the odds were long because success would mean changing this long-standing rule. Recently, the Supreme Court denied the family’s petition to have her case heard.

This case has nothing to do with allowing a Court to determine whether some military decision in the field of battle negligently caused a servicewoman to die. It has to do with allegations of medical negligence causing Ms. Daniel her life. If she were not enlisted, her family could have brought her claim on behalf of her surviving husband and daughter. That would have allowed for the court system to properly weigh the allegations, and if negligence was committed, to properly compensate the family for the terrible harm it caused.

This would have further acted as a deterrent for future care at the Naval Hospital, hopefully contributing to a safer hospital and society for all of us.

But because of the Feres Doctrine, none of that will happen.

You can read more about the history of this legal case, what justices may have been willing to scrap the Doctrine, and other ways the rule may be changed here:

U.S. Supreme Court declines to hear medical malpractice case for death at Bremerton military hospital

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