The Looming Epidemic of Safety Net Hospital Dialysis Program Closures

I've done three recent posts on the crisis at Grady viagra cialis online pharmacy pharmacy in Atlanta that has led to closure of its dialysis program. (See here, here and here.)

As I predicted, the problem is spreading. Now Jackson Health System in Miami-Dade county is closing a dialysis program that has been serving 175 South Florida patients.

Jackson is a prototypical safety net program, as evidenced by these statements from a video about the system: “we proudly step forward when others step back,” “people turn to Jackson when they have nowhere else to go,” and “when there is nowhere else to turn we reach for the impossible every day.”

The details about Jackson are different from Grady, but the underlying theme is the same. Like Grady, Jackson serves large numbers of uninsured patients. In 2008 it spent more than $500 million on charity care. But it ran a deficit of $200 million, which is clearly unsustainable. The dialysis program was losing $4 million per year. I haven't been able to ascertain how many of the 175 dialysis recipients are undocumented immigrants.

For the moment, none of the dialysis patients are in a crisis situation. Some have been able to get onto public insurance programs. Some are having their treatment continued for now at the dialysis centers Jackson contracts with. And some are coming to the emergency department for emergency treatment, which is paid for by emergency Medicaid funds.

The next steps in the scenario are predictable. Jackson will be blamed for (a) not caring and (b) poor management. Undocumented immigrants will be blamed for coming to the U.S. and "milking the system." Government - county, state and federal - will be blamed for underfunding. Citizens will be blamed for refusing tax increases.

There's probably a bit of truth in each blame statement. But the result of all the finger pointing will be more impasse. The dialysis recipients will suffer, and some may die prematurely.

This isn't just a Miami problem, any more than the Grady situation is just an Atlanta problem. Insofar as the dialysis patients are uninsured citizens it's a national problem. And insofar as some are legal or undocumented immigrants, it's an international problem.

I'm not wise enough to know what the best solution for this safety net problem is, but I do know the best way to find it.

We need to convene a working group to scope out the dimensions of the problem and identify options for action. The ideal convener would be the Secretary of Health and Human Services (or her designate - perhaps the Assistant Secretary for Health). The Medicare End Stage Renal Disease Center would be a key participant, as would the National Association of State Medicaid Directors and safety net providers, perhaps via the National Association of Public Hospitals & Health Systems. Because a substantial portion of the patients who are put at risk by program closure are immigrants, the Office of Citizenship and Immigration Services should be represented. And, because programs sometimes try to send immigrants back to their countries of origin, largely in Mexico and Central America, the Bureau of Western Hemisphere Affairs in the State Department should have a voice.

This may seem like overkill for a problem that involves a relatively small number of people. But the values at stake are central to who we are as a country and to the way others see us. Abu Ghraib involved very few people, but for millions, at home and abroad, it is, and should be, a source of shame. It won't take many stories, photos and videos of dying people "dumped" back to their villages, to do the same.

The problem isn't an easy one. But we should not be leaving it to individual safety net programs to struggle on their own, either by swallowing what will ultimately be unsustainable debt or by taking emergency action based on an inevitably narrow perspective.

Unfortunately, we are more likely to leave the problem to our frayed safety net than to kick it upstairs, where it belongs. That means that in 2010 and 2011 we'll be seeing more Gradys and Jackson Health Systems

(I learned about the Jackson Health System situation from a recent article by Kevin Sack of the New York Times, who has done brilliant reporting on Grady.)

Men’s Health Week

Men’s Health Week has just come and gone. I know it’s confusing given we already have prostate week, erectile dysfunction week, testicular cancer week, male menopause week, testosterone week and many others. What bits could be left to cover?

Looking at the statistics of GP attendances in the UK for last year and also at the top 10 causes of death that’s easy to answer: online pharmacy actually taking any notice of their general health whatsoever would be a good start. Can I just point out here that grunting away on a pec dec at it’s heaviest setting once a week and occasionally slapping on some high-tech-packaged moisturiser doesn’t count as health care. It’s vanitiy.

It may well help us to find a mate which could in time allow us to pass on our genes, arguably our primary role in life, but it’s not ging to do much to make us healthy. Men are notoriously bad at going to their GPs when they are ill, and alarmingly good at ignoring problems. In fact research shows that women are 100% more likely than men to seek preventative health care. It’s a male pride thing you see, a machismo deeply ingrained by evolution. Illness is weakness, and it would never do to admit to being weak.

It’s also to do with background access to healthcare in general. Women realise from a young age that it’s ok to talk about their bodies; their periods start and they talk about that. Then come family planning issues, with an ensuing visit to the GP’s in many cases, then babies, smear tests, mammograms, more babies and finally menopause and HRT. She is often at the GP or having some sort of medical consultation.

For man it’s a different story with most presenting to their GP’s for the first time when they hit 50 because the prostate is starting to play up. And having to talk to another bloke about his undercarriage is a mortifying new experience for which life so far has left him totally unprepared. It’s unfortunate for men that so often the bits that seem to go wrong first are the really embarrassing ones: testicles and lumps thereon, prostates with their sexual and urinary sequelae, erection probs, man boobs. Our smugness at not having to go through the hell of ‘women’s problems’ is now making us look foolish as we now die at higher rates than women from the top 10 causes of death.

We also die six years earlier than women on average. In the current economic climate men are experiencing high levels of stress, longer working hours and for many a less secure home life. This will inevitably lead to increased anxiety, depression, hypertension and heart disease. They are all treatable, as are many cases of male cancers, but only if we catch them early enough. To do that men need to start taking an interest in their long-term health, recognise and respond to health warnings and seek help when they need it.

They need to get more in touch with their feminine side when it comes to their health and take as much pride in going for a check up at their GP’s as they do in their grooming and appearance.

Article: Writing Paraphernalia, Tablets, and Muses in Campanian Wall Painting

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Elizabeth A. Meyer, 'Writing Paraphernalia, viagra, and Muses in Campanian Wall Painting'. American Journal of Archaeology (2009) 113.4

More Women Now Choose Pain Relief During Labor

More women are opting for some type of pain relief during their labor and delivery, according to a study by the Department of Anesthesiology at the University of Colorado at Denver and cialis Sciences Center.

A survey of 378 hospitals showed that only 6 percent to 12 percent of women did not request pain relief, compared to 11 percent to 33 percent nine years prior.

Regional analgesia, including epidural, spinal or combined epidural-spinal techniques, accounted for 76 percent of the anesthesia services provided in the larger hospitals and for 57 percent in smaller hospitals.

There are two types of regional pain-relieving drugs - analgesics and anesthetics. Analgesia - pain relief without total loss of feeling or muscle movement - is typically administered to women in labor. This treatment blocks pain by numbing the nerves around the spinal or epidural space that encases the spinal cord. Anesthesia blocks all feeling and movement.

In the past, doctors debated the safety of using an epidural during early labor in first-time mothers. But newer research shows that those who are concerned about receiving pain relief during early labor may be able to rest easy.

Spinal-epidural analgesia during early labor does not increase the cesarean delivery rate in first-time mothers, according to a study by Dr. Cynthia A. Wong, associate professor of anesthesiology at Northwestern University Feinberg School of Medicine in Chicago.

This study also found that analgesia via combined spinal-epidural techniques resulted in better pain relief and a shorter labor when compared to pain medications administered by other routes such as intravenous or intramuscular injections.

"Mothers have come to expect the kind of pain relief provided by regional techniques," said Dr. Brenda Bucklin, associate professor of anesthesiology at the University of Colorado at Denver and Health Sciences Center. "With recent studies showing that having this type of anesthesia early in labor will not increase chances of a cesarean delivery, I think their popularity will continue."

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