Chicago’s innovative plan to help deliver better medical care to its urban poor and decrease overall costs is proving more successful than critics originally anticipated. It sprung from the observation of University of Chicago Hospital’s executives that more than 40% of the over 55,000 patients who appear in its emergency room annually could be better and more efficiently served in a clinic or primary care physician’s office. The University of Chicago’s Urban Health Initiative was started in 2005 as a way to educate urban patients on when to use the emergency room and when to go to a clinic.

Innovative Chicago Hospitals Improve Care in Urban Areas

The program links each patient to a non-ER medical home where they can make appointments for non-emergency issues. The program was once led by Michelle Obama and has linked 5600 people to a medical home since it began. The idea behind finding patients a medical home is that redirecting non-emergency needs to a primary care physician or specialist at a clinic will result in higher-quality care for patients than they would receive at hospitals where costs are also much higher than at clinics. Decreasing the number of patients appearing unnecessarily for routine issues in emergency rooms will increase both cost-efficiency and quality of care.

Though these patients are not maintaining a consistent relationship with one doctor after they are referred by the University of Chicago to its directory of primary care providers, they are maintaining a closer relationship with a facility (their medical home) which helps target the national problem of those with chronic conditions not seeking preventive care. Increasing the rate at which these chronic conditions are addressed earlier and more consistently not only helps prevent premature deaths but also saves the healthcare system tens of billions of dollars. Though the problem of not seeking preventive care from a primary care doctor regularly is a national issue that transcends income groups, the problem is most severe in low-income neighborhoods such as those served by the Urban Health Initiative, where doctor’s appointments are low on the list of priorities.

The Urban Health Initiative has grown to include 24 community-based clinics and other providers and has a budget of over $6 million annually. The number of appointments made at clinics through program referrals have jumped nearly 40% to 3649 in the last year, compared to 2006. Critics point out however that in 2005 34% of patients (884 people) who were referred by the program kept their appointments at their medical home clinic. In 2010, that number has grown to 1386 patients – only 39% of all referrals.

Despite this criticism, the success of the program has been lauded nation-wide, to the point that the Urban Health Initiative is now poised to escalate research initiatives and teaching opportunities for physicians hopefully leading to its being a national model for medical care in urban areas.

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As the school year revs into gear, food allergies will weigh heavily on many parents’ minds. According to the United States Center for Disease Control, more than 3 million children enrolled in schools had a food allergy in 2007, up nearly 20 percent from a decade earlier.  Many of these food allergies are life threatening, with kids going into anaphylactic shock after unknowingly consuming peanut, milk, or soy products.

While there are many guidelines for schools, there is no wide sweeping federal mandate regarding students dealing with food allergies. Many students avoid allergic reactions by sitting at special peanut-free lunch tables or classrooms for severely allergic students. However, many parents protest segregating students because of their food allergies.  Another group of parents want to completely ensure their children’s safety, and encourage peanut-free zones in the cafeteria. Other parents want a complete ban on peanut products: unfortunately, it is very difficult to completely ban peanut butter and other related products from schools. Peanut butter and jelly sandwiches are often the centerpiece of a child’s lunch, as they are easy to make, nutritious, and relatively inexpensive.

Still, allergies have grown into a critical issue at many schools throughout the country. More children and adults have food allergies than ever before.  According to a study at Children’s Hospital in Boston, Mass., the number of food related allergic reactions in children doubled from 164 cases in 2001 to 391 just five years later in 2006. The study also noted an increase in anaphylaxis, one of the most dangerous types of allergic reactions. When a person goes into anaphylactic shock, they may experience sudden rash, breathing issues, dizziness, vomiting, and a dramatic blood pressure drop. More than 30,000 individuals, children and adults alike, will go to the emergency room for allergic reactions to food every year.

Nut Allergies a Rising Concern in American Schools

While some children outgrow their allergies, some still suffer from food allergies well into adulthood. Those allergic to peanuts and tree nuts suffer from more severe reactions, and they are also less likely to outgrow their allergies as they grow older. As a result, managing care for food allergies in colleges and universities has grown more important in the 21^st century.

Colleges are working hard to give students with food allergies safe food alternatives. Although an estimated 4 percent of the population has a food allergy, only a small percentage of these college students ask staff for help finding alternatives. Still, many colleges offer frozen meals and gluten free bread for such students. At Franklin and Marshall College, dining halls are completely nut free and foods like granola are clearly marked so allergic students can avoid them.  Other schools like Tufts provide online menus with clickable ingredient lists, and food cards made for every meal on the menu to ensure safety.

At the College of the Holy Cross, students have access to a wide variety of allergy free meals. Students can pre-order such meals from the campus dining hall, where staff makes meals specifically for the student.  In the case that the student forgets to order meals in advance, the dining hall boasts an allergy free kitchen stocked with supplies necessary to make a meal. This approach allows students to eat with friends despite their allergies.

While many universities across the country are working hard to improve food quality for students, there is still much to be done for younger students.  It is imperative that we make school cafeterias and mealtimes safe for our children, no matter what their age or allergy.

Last Tuesday August 3, 2010 Missouri voters overwhelmingly approved Proposition C, a ballot measure that would prohibit the state government from requiring residents to have health insurance or from penalizing them for not having coverage. The referendum – now Missouri law – is in direct conflict with the individual mandate that’s part of the Patient Protection and Affordable Care Act of 2010. The federal requirement that most citizens have health insurance or face penalties begins in 2014. Because federal law generally overrules state law, the vote was largely symbolic as a show of the Tea Party movement’s strength and of popular discontent (particularly among conservative voters) with healthcare reform.

Missouri Opposes Federal Individual Mandate

71% of Missouri voters approved the measure while only 29% voted against it. Though turnout for the vote was low, the vast majority of those who did vote were Republicans. Analysts know this because even though Missouri’s open primaries do not require voters to register their party affiliation, many more voters took Republican ballots than Democratic ones. Republican legislators originally wanted to put Proposition C on Missouri’s November election ballot as a vote on a constitutional amendment, but to avoid a Democratic state senate filibuster they settled for a proposed law on last week’s primary ballot.

The purpose of the federal law’s individual mandate is to widen the pool of healthy individuals covered by insurers to balance out the influx of unhealthy individuals expected to enter the pool as a result of separate provisions which prohibit insurers from denying people with pre-existing medical conditions. Were there not to be an individual mandate in conjunction with eliminating denials based on pre-existing conditions, premiums would rise out of control.

Though this is nothing more than a symbolic gesture of disapproval from voters, several other states have also passed similar statutes not based on referenda, including Arizona, Georgia, Idaho, Louisiana, and Virginia. Arizona and Oklahoma voters are set to vote on state constitutional amendments to the same effect in November. In the same vein, public officials in more than twelve states (including Missouri) have filed lawsuits claiming the individual mandate violates usual federal-state relations. Defenders of the law argue the mandate falls under Congress’s power to levy taxes and regulate interstate commerce. Federal courts are expected to weigh in on the constitutionality of this issue before the individual mandate goes into effect.

A number of high powered interest groups were involved in campaigning for Proposition C. The Missouri Hospital Association was particularly vocal – to the tune of $400,000 – in warning voters that passage of the measure could increase hospital costs for treating the uninsured. The group argues that were there not to be an individual mandate, there is the potential for a massive cost-shift onto the insured to cover those visiting emergency rooms because they lack insurance. There was little opposition from grass-roots organizations or unions and consumer groups who had forcefully supported reform earlier this year.

The latest destination for medical tourism for American patients isn’t a tropical locale – in fact, it’s right here in the US. That’s right – some large employers are negotiating with hospitals in other states and paying for employees covered by the company health plan to seek treatment for major illnesses and surgeries outside their home counties. Hospital care accounts for over 1/3 of our $2.5 trillion annual health spending and this amount is projected to rise drastically according to government data – it rose nearly 6% last year alone. This increase is being driven both by increased use of hospital services and rising prices. In the face of this looming increase, large employers are trying to save money on their company health plans by negotiating a single rate with top-quality hospitals in other states which includes the fees for all medical services until the patient is discharged.

To encourage workers to use the program, companies waive deductibles, cover travel and hotel costs for patients and their families, and reduce co-insurance payments by as much as half. Even factoring in travel costs on the company tab and in some instances monetary incentives to workers, most large employers who’ve tried “domestic medical travel” say they can reduce their costs 20-40% by directing workers to facilities with higher-quality care and lower negotiated prices. Employers who’ve promoted domestic medical travel include Alpha Coal West, BridgeHealth Medical’s group of small and midsize companies, and the Health Services Coalition of employers and unions in Nevada. Alpha Coal West has reported its medical costs have remained flat even as such spending has risen nationwide in the nine years since it implemented the program.

Medical Tourism in the US

If domestic medical travel becomes popular amongst large employers, health industry experts argue the shift could improve quality of care overall and help drive down costs by “fostering a truly national competition.” Savings with domestic medical travel programs result not only from lower prices (negotiated between the company and the out-of-state hospital) but from fewer complications with procedures done at high-quality hospitals. Better hospitals perform procedures better, meaning fewer costs incurred after surgery to resolve complications. Any necessary follow-up care (like physical therapy) is usually performed at the local hospital and covered under the company’s normal insurance plan.

The concept of domestic medical travel is really nothing new; employers and insurers have always sent patients to very high-quality facilities for complex procedures like organ transplants. Domestic medical travel is taking this idea to another level, applying the same concept to more types of medical care like back, knee, and heart surgeries.

Some critics argue the movement toward domestic medical travel could backfire if employers and insurers forget about quality and focus only on cost-savings. Also, some workers (even with incentives and paid travel for patients and family members) are reluctant to travel for surgery. Though the programs are now voluntary, critics worry they may become mandatory and force patients to travel for their procedures even when they don’t want to. For these reasons, and because such programs can anger the local provider community, some insurers are reluctant to encourage domestic medical travel.

These considerations do not seem to be hindering the trend toward domestic medical travel, especially since major companies like Alpha Coal West have experienced such success (and savings) with their programs. It appears as rising medical costs continue to increase nationwide, domestic medical travel is the way of the future for major companies to flatten escalating costs while simultaneously providing their employees with the best quality of care.

Medical residencies are notorious for their excruciatingly long shifts.  Doctors fresh out of medical schools use their residencies to gain on the job experience in their desired specialty. Although residencies allow these young doctors to develop expertise, the long work hours can take a toll on their minds and bodies. Residents practice under the supervision of licensed doctors and continue their training as physicians.

In the past, a medical resident could expect to work more than 100 hours a week, with minimal rest in between. Things changed in 2003, when the Accreditation Council for Graduate Medical Education (also known as ACGME), cut down the hours to 80 weekly, although this ruling was not strictly enforced. Still, many shifts can last over a day, up to 30 hours with limited time to sleep.

A new proposal set by ACGME will cut down on mistakes and ensure that patients are safe.   Maximum shift lengths would be reduced hopefully reduce harmful medical from 24 hours to 16 hours for first year residents and to 24 hours for all other physicians. Additionally, attending physicians would be required to make patients aware that they are under the charge of a resident.  The new guidelines will require attending physicians to supervise residents more closely in an effort to improve patient safety. Still, these regulations would only affect first year residents. All other physicians would limited to 24-hour shifts.

Studies have shown that sleep-deprived residents are more prone to making medical mistakes.  A Mayo Clinic study revealed that fatigued, distressed medical residents were more likely to make preventable medical mistakes. Yet another study found that residents were three times as likely to say that they’d made an error during months when they worked one 24 hour long shift.  In 2004, a report discovered that medical residents who worked all night shifts were ultimately accountable for over half of medical errors.

Overworked Medical Residents May Be Catching a Break

Ultimately, some medical mistakes prove fatal. One famous medical malpractice case is that of Libby Zion, an 18 year old college student who died when her overworked, fatigued medical residents prescribed her medication that reacted dangerously with her antidepressants.

Grueling shifts can compromise the health of the doctors themselves. Dr. Shannon Gulliver recently wrote a piece for the New York Times in which she detailed her own weakened immune system, a result of the long hours and high stress of her position. She developed esophagitis, while her colleagues themselves developed shingles, fungal infections, C. difficile diarrhea, and more.

While education is undoubtedly a priority during residency, maintaining the health of both doctors and patients is equally important.  As long as these regulations can cut down life threatening mistakes, I feel that cutting back these hours can be a good thing. Medical residents will still be able to gain the experience they need to practice, and after they complete their first year of residency, young doctors will only be restricted to 24 hour shifts. Ultimately, these guidelines will improve quality of care for patients and better health for doctors and patients alike.

The 2010 health care reform has been the center of debates since it was passed this past March. One key aspect of the new legislation was the mandate that new health insurance plans must offer free preventative health care to patients in an effort to improve the overall health of the country.

However, including one service in the preventative care has been a source of contention for many groups. Namely, that service is free contraception and family planning services for women.

Should Birth Control Be Included Under the Preventative Care Mandate?

According to Michelle Andrews from Kaiser Health News, American women spend an average of 30 years attempting to prevent pregnancy, and only five years of their lives actively trying to become pregnant. Birth control is one important approach to family planning, and many women’s and employer groups argue that it should be deemed a preventative service.

Still, many more conservative groups oppose including contraceptives in the preventative care mandate, honing in on the support of socially conservative voices. The U.S. Conference of Catholic Bishops argues that pregnancy is not the same as a disease, and therefore contraception should not be placed in the same category as preventative care.

Already, 27 states include birth control as preventative care measures. According to Ms. Andrews, there are over 3 million unplanned pregnancies nationwide every year—a product of the high cost of birth control. Women who use the birth control pill as a contraceptive can expect to spend nearly $75 every month to prevent pregnancy. Not surprisingly, many unexpected births can be attributed to the high cost of birth control options like the pill and IUDs (intrauterine devices).  Even when health insurance plans provide birth control, copayments could still be too high for women—ranging from $50 for the birth control pill and hundreds for IUDS. Young women in particular are hit hard by the prices.

And remember—even married women use birth control to prevent unwanted pregnancy. In fact, over 11 million American women use contraceptives.  Unplanned pregnancies actually cost the American health care system over 5 billion dollars every year—and 40% of these births are covered by Medicaid. Low-income women on Medicaid are less likely to have access to affordable birth control. Plus, many health plans for individuals do not include maternity coverage.

Some employer groups argue that offering contraceptives as a part of preventative care will decrease the cost of insurance, as prenatal and postnatal care is far more expensive than the cost of birth control.

Still, the issue is a touchy one—pregnancies are not as black and white as diseases.  To the millions of American on birth control, hoping to avoid pregnancy, birth control is a crucial part of preventative care. To other Americans, pregnancy is not a disease to be prevented, but the gift of a life. Thus, birth control—like the new morning after pill, Ella One— falls into the health care reform’s gray area of morality.

Despite the tremendous cost benefits that providing contraception would provides—as well as a high demand, the White House took the politically safe route and opted not to include contraception in the preventative care mandate.

In the early years of the HIV/AIDS pandemic, receiving an HIV diagnosis seemed like a death sentence. During the 1980s, with little scientific knowledge about the virus, doctors could not treat HIV/AIDS and AIDS deaths rose rapidly from year to year.  The AIDS death rate peaked in the mid 1990s, finally slowing down when doctors began administering highly active antiretroviral therapy (HAART), drugs which substantially increased the lifespan of an HIV positive person.

HIV/AIDS Drug Assistance Programs Impacted By Recession

Now, HIV positive people depend on HAART to live. Drug therapy for HIV/AIDS is incredibly expensive: one Florida man’s medications cost him over $4,500 monthly, ringing up at around $54,000 every year.  Most HIV positive people simply can’t afford the skyrocketing costs of their prescriptions. Many of these people instead rely on the AIDS Drug Assistance Programs (ADAP), where they only have to pay $12,000 for their drugs.  Currently, AIDS Drug Assistance Programs serve around 170,000 who are unable to buy these mind-numbingly expensive drugs.

However, because of the recession, AIDS Drug Assistance Programs have been hit hard.  In order to balance strained budgets, many states have squeezed their ADAPs, forcing thousands of people nationwide onto waiting lists and off their prescriptions. Many states have either created more strict requirements for enrollments or trimmed their prescription drug formularies in order to keep the programs afloat. At the same time, more and more people are applying for assistance because of the high unemployment levels, squeezing the ADAP’s resources even more.

The effectiveness of HAART has also contributed to the ADAP crunch.  Because of drug therapy, HIV positive people are living longer because the drugs more successfully slow the progression from HIV to AIDS.  At the same time, the CDC’s HIV testing initiatives has resulted in more people knowing their status sooner, adding even more people to the ADAP pool.

Some people on the waiting list have been able to procure drugs from other resources: some pharmaceutical companies offer free or discounted drugs to qualifying patients on a temporary basis. Still, gaps in HAART can have deadly consequences for patients.  HAART most effectively suppresses HIV when used consistently: when patients are off drugs, the HIV viral load increases and can even reduce the effectiveness of those drugs.  When patients skip doses, the AIDS virus becomes resistant to that drug.

Ultimately, these programs need more funding. The government made a commitment to HIV/AIDS when it began promoting increased HIV testing and renewed the Ryan White Act, and it should thus help defray the costs of drug assistance. The states are not economically equipped to fund these programs.  The National Alliance of State and Territorial AIDS Directors have requested $126 million dollars worth of funding to keep their programs afloat and patients alive, a number which dwarfs President Obama’s proposed $20 million in additional funding. Meanwhile, several Republican senators want the whole amount to be paid for from Department of Health and Human Service stimulus.

For people relying on state AIDS Drug Assistance Programs, enrollment in an ADAP can mean the difference between life and death. It is imperative that the United States continue its commitment in the war against HIV by increasing funding for such crucial programming and in turn, save lives.

Medical experts have developed a new morning after pill that claims to be better than any other emergency contraceptive pill.  It is called ellaOne.  The attraction: it works for 5 days! You can take the pill for up to five days after unprotected sex and it will work as well as if you took it the morning after.  Its leading competitor, Plan B, only works for up to 3 days after unprotected sex.  This could be the answer to many unwanted pregnancies.

Will EllaOne Be Available in the US?

However, as expected, it raises the ongoing abortion debate.  This new pill, ellaOne, delays ovulation and therefore inhibits conception.  It does so by preventing the progesterone hormone, a hormone that causes females to ovulate, from being released in the female body.  Conversely, those who are on the pro-life side of the debate claim that it is an abortion pill.  They believe that the pill does not prevent this hormone from being released.  Rather, the fact that it works for five days leads them to believe that it stops the fertilized egg from being implanted in the female’s uterus; therefore killing the fertilized egg.  This being the case, then they consider it an abortion.  If the pill was used the morning after, fertilization may not have taken place.  But, by the fifth day fertilization has taken place.  Nevertheless, some assert that the pill does both: it delays ovulation and prevents the fertilized egg from implanting in the uterus.  So the question is: how does it really work?

This debate has not stopped the pill from being released.  Medical experts find that there are more benefits to it than drawbacks.  No major side effects of the pill on women’s health have been found.  If you take the EllaOne Pill within this five day window, there is only a 1.8% chance of you becoming pregnant.  Whereas, with Plan B you have a 2.6% chance of becoming pregnant.

EllaOne is not yet available in the US.  There was a recent assembly in the US where the Federal advisory panel of medical experts met to discuss the potential sale of ellaOne in the US.  These 11 experts unanimously voted in approval of the emergency contraceptive pill.  Now, the FDA will take this vote into consideration as they decide whether or not to allow the sale of ellaOne in the US.  If the FDA approves the pill, it will be available in the US by prescription only; not over the counter.  However, you will need to check with your health insurance provider to see if this contraceptive pill is covered by your insurance plan.  This final decision by the FDA could take up to several months.  EllaOne is currently sold in France (where it originated) and Great Britain.

The debate over whether the new federally-funded high risk pool programs will allow funding for member’s elective abortions continues. The mandatory state high risk pools will be funded at least in part by the federal government and in some cases also federally administered, though many states have volunteered to administer the pools themselves and contribute the lion’s share of funding. The pools –referred to as “pre-existing condition insurance plans” – are meant to provide health insurance for residents with pre-existing conditions who would otherwise be ineligible for coverage. Last week, the Obama administration announced it would not permit funding to be used for elective abortions under the program. This angered pro-choice groups who argue the President is bending over backwards, compromising campaign promises to appease a few pro-life Democrats.

Will Obama Fund Abortions in High Risk Insurance Pools?

Pro-choice advocates further allege that the administration does not have the legal authority to determine whether funding can be used to pay for abortions, as the use of funds for such procedures in high risk pools was not mentioned in the language of the Affordable Care Act or the subsequent executive order. Pro-lifers and Republicans say that even if the high risk pools were not included in the language of the executive order which affirmed the Hyde Amendment, the principle of the deal which solidified pro-life Democrats’ last-minute votes should still apply. Essentially, the President promised Democrats the reform would neither expand nor contract abortion availability, and his office should keep that promise.

Abortion-rights groups respond that many states’ existing high risk pools currently cover abortions for good reason. Many of the women enrolled in high risk pools have chronic health problems like diabetes which can make pregnancy dangerous. Abortions must be available to these women as a backup plan if their birth control fails as a pregnancy could seriously threaten their health, or even their lives.

Numerous studies have proven loving (and being loved by) our pets keeps us healthy. In addition to the wonderful companionship and assistance that service animals provide for their owners such as the blind or children with autism, pet ownership has been shown to lower one’s risk for heart ailments. Some studies have even shown dogs are able to detect health problems like seizures and diabetic attacks. With these facts in mind, the New York Times Well blog recently asked readers “How does your pet keep you healthy?”

My dog Lace has kept me healthy by being a great exercise buddy. When she was a puppy, Lace was the runt of her Golden Retriever litter. But by the time she was two, Lace had grown to a very portly 100 pounds – far exceeding the healthy weight for her breed. We took her to the veterinarian to make sure she was clear of all possible thyroid or other problems, and she was given a clean bill of health. The veterinarian told us that because we tended to feed Lace table scraps after dinner, she was gaining too much weight. We needed to keep her on a strict diet of diet dog food and exercise her much more regularly to ensure that her doggy obesity didn’t impact her health.

My Dog Before Our Workouts - Such a Porker!

Around this time, I had decided to sign up for a club volleyball team. To get both of us back in shape, Lace and I decided to become jogging partners. We ran around my neighborhood each day, starting out slow and eventually working up to hour-long jogs down the hilly streets of our town. Lace was even more enthusiastic about our plan than I was! Even when I saw a hill ahead and started to slow down, she just kept pushing, encouraging me to run farther. I’m happy to report that both Lace and I have managed to stay in shape by continuing our daily runs, and that she’s now a healthy 75 pounds.