The Snooki tax, a 10% tax on indoor tanning services, that appeared as part of the ACA and its sister bills may or maynot be “working,” to reduce the use of indoor tanning services as some of the authors intended.
The impact of the tax on consumer behavior remains unclear. Only 26% of salons surveyed reported experiencing fewer clients after implementation of the tax, and distinguishing the impact of the tax from the current economic climate as the source of decline was difficult. Furthermore, a large number of respondents (78%) reported that clients did not seem to care about the tax.
Study participants frequently reported that the salon’s younger and first-time clients were less likely than its older clients to notice or care about the increased prices resulting from the tax. Taken as a whole, these results may indicate that the demand for indoor tanning services is somewhat inelastic and perhaps insensitive to a 10% tax level.
I’m not a proponent of targeted taxes in general; certainly not those targeted to influence behavior. I don’t support the cigarette tax and I don’t support any hypothetical soda taxes and I don’t support the indoor tanning levy. And I wouldn’t be surprised at all if, at 10%, the influence of the tax was nothing or so small as to be impossible to detect.
A group of public health researchers out of UCSF and Columbia have a piece in the pending edition of Health Affairs. In it they argue that 1c per ounce tax on sugar sweetened drinks would,
prevent 2.4 million diabetes person-years, 95,000 coronary heart events, 8,000 strokes, and 26,000 premature deaths, while avoiding more than $17 billion in medical costs
over the next ten years. If you can’t access the full study on Health Affairs behind the firewall then here’s a write up on a Los Angeles Times blog.
First and foremost I have a major problem with taxation to influence behavior. I don’t even like the federal tax on cigarettes. I understand the public health issues involved in second hand smoke. Even factoring those I think something like the tobacco tax, which is beyond discredit in terms of its success, is beyond the purview of the government.
And the junk food tax is likely to be something less effective than the tax on cigarettes and targets a behavior with far few social costs; even admitting that the bill for diseases associated with obesity is footed in part by society in general it is a far cry from say the public health effects of second hand smoke.
Plenty of previous data finds the conclusions of the Health Affairs paper optimistic.
[A] trio of economists analyzed 16 years of U.S. household health data to study the feasibility of using a soft-drink tax to help Americans lose weight. In a 2008 paper, the researchers calculated that a 1-percentage-point increase in the tax would reduce the average body mass index by just 0.003 units.
In other words, an overweight person with a BMI of 27 would end up with a BMI of 26.997 — still well short of the 20-25 range considered healthy.
Even a soft-drink tax increase of 20 percentage points wouldn’t help much, because soda accounts for only 7% of calories in the American diet.
I am highly dubious rising the cost of a can of soda 12c or a six pack by less than a dollar is liable to significantly discourage use.
Tobacco taxes are also much higher than anything likely to be adopted for food and beverages. Slapping a 10% tax on a $1.50-bottle of Coke would raise the price a mere 15 cents — not enough to persuade most shoppers to drink Diet Coke instead. Many calorie-laden foods are simply too cheap to be priced out of the market by any but the most draconian of taxes.
As well, such a tax would be highly regressive since sweetened drink use is inversely proportional to socioeconomic status (myself excluded of course; I go through 4-5 sodas a day).
In the end though, like I said, I just don’t like the idea of government dictating what we should and shouldn’t be eating and drinking. Their role in such, with agricultural subsidies and regulations of commercial foodstuff is already too big. The idea of a tax to specifically influence or diet is too much to take.
The primary care-specialist income gap isn’t new. But here‘s more data on it:
$100/Hour and More
Neurologic surgery: $132.33
Radiation oncology: $126
Medical oncology: $114.21
Plastic surgery: $113.78
Dermatology: $102.68 $80 to $93/hour
Cardiovascular diseases: $93.74
Gastroenterology: $93.27
Neurology: $92.52
Emergency medicine: $87.47
Obstetrics and gynecology: $83.40 $66 to $75/hour
Neonatal and perinatal medicine: $75.86
Psychiatry: $72.24
Pulmonary diseases $71.67
Pediatrics $69.24
Child and adolescent psychiatry: $67.36 $58/hour and less
Family practice: $58.25
Internal medicine: $58.18
General practice: $57.55
From the future top the discrepancy is ridiculous. For a spine surgeon to be making more than 275% more per hour than some primary care physicians is ridiculous. And you know my opinion is sincere because I used the same adjective twice.
The trouble is I don’t think what the neurological surgeon earn is outrageous or unreasonable. The primary care physician just needs to be earning more.
becoming the largest provider of primary healthcare services in the nation.
Retail primary care physician directed care is nothing new. The first one opened in 2000. But their promise has been largely unfulfilled and, while they may have found a nitch market, the idea of them redefining primary care or supplanting the traditional internist office appears at present as a pipe dream. I know consultants and the industry say differently but I’m of the opinion the retail clinic industry promoted itself as having grown further and achieved more than it has to date. But then again maybe Walmart can do differentially.
I’m not sure I’m convinced of the feasability of some of their goals. For instance, I’m not sure there’s major cost savings to be had in this model. Whatever this model turns out to be.
What it may do, and what I think everyone should be on board with, is expand access to care.
“It’s a really big deal,” says Bob Kocher, a former health policy adviser to President Obama. “We have a shortage of primary care and of access. If Wal-Mart comes in, that creates a lot more access in areas where it’s been hard to find a doctor. This could bring low prices and relaible quality in a way that we don’t really see right now.”
The population attracted to retail clinics, in stores like Walmart, is a population already largely underserved. Even if the cost of health care becomes less of a hurdle as the ACA is implemented, a serious venture into primary care services by a major player like Walmart, if played right, could really expand care to a population that would benefit from it.
The New York Time has a profile of a gentleman, illegally in the country, who spent 19 months in a New York City hospital because there was no funding for the out of hospital assisted care he was going to need.
[T]he hospital admitted Mr. Fok to the intensive-care unit on the third floor, where workers tried to find out more about their patient — not just his medical history, but his insurance or Medicaid status, his address, his Social Security or taxpayer identification number, the location of family members.
Once his condition had stabilized, the hospital moved him to a regular room on the fifth floor, where staff members expected to treat him for 7 to 10 days before discharging him to a sub-acute-care center for rehabilitation, the usual regimen for stroke victims.
Nineteen months later, Mr. Fok, 58, greeted a reporter from his bed in Room 516, eager to have a visitor. In the previous year and a half, perhaps 100 or more patients had come and gone from the room’s other bed, but Mr. Fok had gone nowhere.
Near the border here in Texas this is not an unusual problem. Plenty of illegal immigrants with serious, emergent problems are seen at my primary teaching facility. Many a times they end up in conditions necessitating long term care. With no funding, with no public non-acute health care system in Mexico there really are no options but to keep them in the hospital until charity funding is identified for them.
To be fair the profile goes over the active measures the patient, Mr. Fok, took to impede his placement and his care. Many times the patients I encounter have family and friends who will actively work to help in trying to get the patient to a better place outside the hospital, but with limited resources and unable to provide the care he needs themselves it proves difficult.
Mr. Fok’s immigration status never kept him from receiving treatment, but it helped make sure that his care would be delivered in the most expensive setting possible and in a place no one wants to spend more time than necessary. He was cut off from his family. On several occasions he showed signs of depression or expressed suicidal thoughts.
If he had been insured or immediately eligible for Medicaid or Medicare, he might have gone to a nursing home after a week or two, where the average daily cost in New York is about $350 — and where he might have had steady companionship. Or he might have received a home health aide in his apartment, which could have cost even less, depending on the required hours.
For hospitals like Downtown that treat many illegal immigrants, the health care plan enacted last year does nothing to solve this liability, Mr. Menkes said. During debates about reform, lawmakers insisted that the plan’s benefits not extend to the nation’s 11 million illegal immigrants.
As more nurses, pharmacists and physical therapists claim this honorific [title doctor], physicians are fighting back. For nurses, getting doctorates can help them land a top administrative job at a hospital, improve their standing at a university and win them more respect from colleagues and patients. But so far, the new degrees have not brought higher fees from insurers for seeing patients or greater authority from states to prescribe medicines.
So the debate over scope of practice and titles begins again in The New York Times.
As ancillary staff within the healthcare system get more and more advanced and as more and more independent care falls to them the lines between physician and other health care practitioners has blurred. Nowhere more vain than in the use of the title “doctor.”
We know the lengthy history of the title in Europe; rising with emergence of the post-Medieval university. In the United States however almost exclusively in social and professional spheres it has been used to refer to physicians. Not chiropractors or pharmacists or nurses or physicists or poets or mathematicians or lawyers. When you introduce yourself to a patient, or indeed anyone, as a “doctor” their first question isn’t, “Doctor of what?” or “What type?” There is a norm and understanding that you’re introducing yourself as a physician. And there’s nothing wrong with that norm; it merely is the way it is.
As Doctor Steven Knope put it in an NPR article from several years past,
“If you’re on an airline and a poet with a Ph.D. is there and somebody has a heart attack, and they say ‘Is there a doctor in the house?’ — should the poet stand up? Of course not.”
It’s ego partly, admittedly. But especially amongst primary care physician, it may also be about future competition and scope of practice,
[M]any physicians are suspicious and say that once tens of thousands of nurses have doctorates, they will invariably seek more prescribing authority and more money. Otherwise, they ask, what is the point?
Dr. Roland Goertz, the board chairman of the American Academy of Family Physicians, says that physicians are worried that losing control over “doctor,” a word that has defined their profession for centuries, will be followed by the loss of control over the profession itself. He said that patients could be confused about the roles of various health professionals who all call themselves doctors.
I see slippery slope and the worry from physicians. “Doctor” has always been an unregulated honorary title. It has become socially acceptable only for use, outside academics, by physicians. To use it otherwise was to draw snickers or scorn. But the rise of a largely independently practicing class of advanced, doctoral degree holding nurse practitioners provides a challenge to the title. Here are practitioners holding advanced degrees, performing many but not all of the same health care delivery that physicians give. There may still be quizzical looks at cocktail parties when the title “doctor” is used but there are bound to be fewer and fewer of such in the clinic as “physician extenders” with professional doctoral degrees take on more and more responsibility.
In the end while I support the expanded scope of practice for ancillary providers, I’m with Razib Khan. Blogging on the Discovery Magazine website,
[I]n this case we’re seeing greater and greater credentialism in fields which were traditionally perceived to be auxiliary to medical doctors. This is not a good sign. Instead of challenging the unquestioned prominence of medical doctors in domains where nurses are sufficient and more cost effective, the nursing profession is “fighting fire with fire.” This is not going to end well
Whatever my opinion I think the tide likely favors the advanced non-physician practitioners. It will be a slow generational shift but no doubt someday in the future it will be almost universally socially accepted that there are non-physician “doctors.”
I like Al Jazeera, I think it does some really good reporting. They have a documentary series called People & Power which a couple of months ago ran a piece on pain control in the developing world.
The conclusion of the piece is really incredible. They find that the main obstacle to pain control for patients in most of the world is not costs or drug availability, it is the stigma of opiates and the war on drugs.
Overall, Freedom from Pain reveals that bureaucratic hurdles, and the chilling effect of the global war on drugs, are the main impediments to a pain free world. Patients will continue to suffer until global bodies actively work with countries to exclude medical morphine from the war on drugs, and change the blunt drug laws that curtail access to legitimate medical opiates worldwide. Uri Fedotov, the executive director of the United Nations Office of Drugs and Crime, admits in the film that the war on drugs is cutting people off from pain medication, but offers little in the way of concrete proposals for changing the status quo.
If you have the time it is well worth the 30 minutes to watch the piece.
Currently non-intern physician residents are limited to working 320 hours in any four week period, 24 hours of patient care in any one continuous setting and most have 4 days off in any four week period amongst other rules.
The history of medicine’s self governing bodies limiting resident physician work hours in a patient protection bid has a long history, as do my complaints about such.
But I thought it worth reiterating one of the major problems with these work hours. They can only be policed by individuals who are largely negatively impacted by their violation.
Say you’re a obstetrics/gynecology resident at a program that has some rotations that regularly violate the 80 hours/week (averaged). Let’s say you, and all the other residents in your program, report those violations. That is the only way that programs (and thus medical schools and the ACGME) learn about violations…they ask their residents to report them. Mix in some other things and before you know it your program is on probation from the ACGME and then, a few years later as the work hour violations continue despite best efforts, your program is shut down.
And so now you are an out of work ob/gyn resident who can only blame yourself for self reporting those duty hour violations. Now you have to go out interviewing across the country to find another residency program, costing you potentially tens of thousands of dollars. It’s true that your funding for your resident position (your salary) can travel with you as you look for a new residency program and that the ACGME will almost universally provide a waiver to any program that accepts you to increase the size of their residency program and so your odds of finding another residency program to accept you are high, even if you’re in a competitive specialty. However, that isn’t guaranteed and there’s a small chance you may not find another ob/gyn residency to accept you. Even if you do it means packing up your family and your belongings, leaving your friends and moving cross country.
There’s some evidence that the majority of residents continue to routinely violate duty hour rules, largely without complaint. For one, I’m not sure they see the adverse effects of doing such. For two, knowing the light at the end of the tunnel they swallow the long work hours. And, for three, reporting those violations most negatively impacts the resident physicians themselves.
This isn’t a call for some dramatic shift in how we track resident physician work hours or for mitigating the effects of program violations on residents. This is a call for some return to sensibility and some loosening of the work hour restrictions in the first place.
Groups of people with unique environmental exposures create a place for politics and science to clash. Perhaps the most famous modern example is the long slow march towards government recognition of health problems associated with Agent Orange exposure during the war in Vietnam or, more recently, the debate over environmental factors in Autism.
The unique environmental public health issue for mine and just older generations however may be the exposures of September 11th first responders and clean up crews. Outrage over the lack of government response, foresight and funding for presumed health issues associated with exposure at Ground Zero seems to be a popular news focus, especially as we honor the tenth anniversary of that terrible day.
Over the past decade, most of the millions of dollars spent on helping treat sick Ground Zero workers has been focused on respiratory problems and mental health issues such as post-traumatic stress disorder.
Cancer treatment has been specifically excluded from federal health funding, with officials arguing there has been insufficient evidence to prove any direct link between the toxins present at the site and the disease.
But last week the results of the first large-scale study, published in the Lancet, found that firefighters who were involved on the day of the attacks and in the weeks that followed had a 19% higher risk of contracting cancer.
[...]
“People all around us are getting sick and some are tragically dying. For those who are sick with cancer it’s infuriating to see the foot-dragging in making the link between Ground Zero and the disease.”
[...]
Patrick Lynch, who heads a New York police officers’ union, said: “On September 11, we rescued you. Now it’s your turn to rescue us – New York city police officers who are sick and dying.”
Compared with the general male population in the USA with a similar demographic mix, the standardised incidence ratios (SIRs) of the cancer incidence in WTC-exposed firefighters was 1·10 (95% CI 0·98—1·25). When compared with non-exposed firefighters, the SIR of cancer incidence in WTC-exposed firefighters was 1·19 (95% CI 0·96—1·47) corrected for possible surveillance bias and 1·32 (1·07—1·62) without correction for surveillance bias. Secondary analyses showed similar effect sizes.
Impressive in the abstract and worthy of outrage from first responders, friends and family who anecdotally are struggling with cancer diagnoses. However, the story isn’t so clear on further inspection. Indeed the data from the abstract above are firefighters who served at Ground Zero as compared to other New York City firefighters who did not serve at Ground Zero. When the firefighters who served at Ground Zero are compared to a random cohort of American males however the SIR is just 1.02. A 2% increase in cancer findings and, more importantly, not statistically significant.
One of the problems, as the great blog The Incidental Economist points out, is that the cancer incidence amongst the control group of New York City firefighters who did not serve at Ground Zero was much lower than expected for men (and women) their age. That makes the SIR larger and statistically significant. However, perhaps a better comparison is against an average cohort of American males and in such a case there is no increase in cancer incidence.
All-cause SMRs were significantly lower than that expected for rescue and recovery participants (SMR 0·45, 95% CI 0·38—0·53) and non-rescue and non-recovery participants (0·61, 0·56—0·66). No significantly increased SMRs for diseases of the respiratory system or heart, or for haematological malignancies were found…In rescue and recovery participants, level of WTC-related exposure was not significantly associated with all-cause mortality (adjusted hazard ratio 1·25, 95% CI 0·56—2·78, for high exposure and 1·03, 0·52—2·06, for intermediate exposure when compared with low exposure).
Rescue and recovery workers who served at Ground Zero have had lower all cause mortality over the past 10 years as compared to a random cohort of Americans.
I’m not saying that there aren’t real and terrible diseases associated or potentially associated with exposures at the World Trade Center site. Because there are.
9-year cumulative incidence of asthma was 27·6% (number at risk: 7027), sinusitis 42·3% (5870), and gastro-oesophageal reflux disease 39·3% (5650).
Those are incredible incidences as compared to expected. Those responders served incredibly that day and in the months that followed and deserve our attention and focus. But, at a minimum, we need further studies looking at specific cancer incidences for those serving at Ground Zero, before we race to condemn the lack of support they’re received for diseases dubiously linked to their incredible service
Now excuse my ignorance on the subject but it appears the major offenders in this piece had experiences that pre-dated their availability in the United States without incidence. What I mean is that it appears the high rate of complications and failures is limited to the United States as compared to, say, Europe. That may reflect some clinical difference such as surgeon training or patient selection or something along those lines.
But I wonder how much the litigious culture of the United States works to either:
One, bring these issues truly to light so that perhaps the complications with these hips happen just as frequently elsewhere but it goes under reported without the culture of broad civil court
or
Two, how much these problems are made hyperbolic by the same culture.
There are literally dozens of these videos on YouTube. Is there something comparable in say, Germany?
