Tuesday, March 30, 2010

Obama Health: Health Insurance Reform

Luke Sharrett/The New York Times
Health Insurance Reform!!!

From the New York Times
30 March, 2010

President Obama signed the budget reconciliation bill containing a package of revisions to the big health care legislation after giving a speech at Northern Virginia Community College, a setting aimed at drawing attention to the education component of the bill.

“Today we mark an important milestone on the road to health insurance reform and higher education reform,” Mr. Obama said. “But more broadly, this day affirms our ability to overcome the challenges of our politics and meet the challenges of our time.”

He continued, “When I took office, one of the questions we needed to answer was whether it was still possible to make government responsive to the needs of everyday people, middle-class Americans, the backbone of this country, or whether the special interests and their lobbyists would continue to hold sway like they’ve done so many times before. And that’s a test we met one week ago, when health insurance reform became the law of the land in the United States of America.”

In his speech, Mr. Obama also sought to temper some expectations. “The health insurance reform bill I signed won’t fix every problem in our health-care system in one fell swoop,” he said. “But it does represent some of the toughest insurance reforms in history. It represents a major step forward toward giving Americans with insurance and those without a sense of security when it comes to their health care. It enshrines the principle that when you get sick you’ve got a society there, a community that is going to help you get back on your feet. It represents meaningful progress for the American people.”

So it was Health Insurance reform!!!

Could we be hearing a similar speech from David Cameron?

Monday, March 29, 2010

Obama Health Reform: Lessons For The NHS.

I have reprinted from the Reuters report mentioned in my previous post.  

It was a courageous president to have taken on the might of Health Insurers the way President Obama did with his Health Reform, it is time that England should seriously consider passing legislation to rein in on Health Insurers. Many consider it too late to prevent private bodies taking over our once efficient NHS. By 2014, Health Insurers in the US will not be allowed to "cherry pick". Is that why so many of them are poised to cross the pond? Only time will tell. In the mean time legislation similar to those in the US will at least prevent the kind of things that are happening now over there.
 Murray Waas

WASHINGTON, March 17 (Reuters)  
In May, 2002, Jerome Mitchell, a 17-year old college freshman from rural South Carolina, learned he had contracted HIV. The news, of course, was devastating, but Mitchell believed that he had one thing going for him: On his own initiative, in anticipation of his first year in college, he had purchased his own health insurance.

Shortly after his diagnosis, however, his insurance company, Fortis, revoked his policy. Mitchell was told that without further treatment his HIV would become full-blown AIDS within a year or two and he would most likely die within two years after that.

So he hired an attorney -- not because he wanted to sue anyone; on the contrary, the shy African-American teenager expected his insurance was canceled by mistake and would be reinstated once he set the company straight.

But Fortis, now known as Assurant Health, ignored his attorney's letters, as they had earlier inquiries from a case worker at a local clinic who was helping him. So Mitchell sued.

In 2004, a jury in Florence County, South Carolina, ordered Assurant Health, part of Assurant Inc (AIZ.N), to pay Mitchell $15 million for wrongly revoking his heath insurance policy. In September 2009, the South Carolina Supreme Court upheld the lower court's verdict, although the court reduced the amount to be paid him to $10 million.

By winning the verdict against Fortis, Mitchell not only obtained a measure of justice for himself; he also helped expose wrongdoing on the part of Fortis that could have repercussions for the entire health insurance industry.

Previously undisclosed records from Mitchell's case reveal that Fortis had a company policy of targeting policyholders with HIV. A computer program and algorithm targeted every policyholder recently diagnosed with HIV for an automatic fraud investigation, as the company searched for any pretext to revoke their policy. As was the case with Mitchell, their insurance policies often were canceled on erroneous information, the flimsiest of evidence, or for no good reason at all, according to the court documents and interviews with state and federal investigators.

The revelations come at a time when President Barack Obama, in his frantic push to rescue the administration's health care plan, has stepped up his criticism of insurers. The U.S. House of Representatives is expected to vote later this week on an overhaul of the health system, which Obama has said is essential to do away with controversial and unpopular industry practices.

Insurance companies have long engaged in the practice of "rescission," whereby they investigate policyholders shortly after they've been diagnosed with life-threatening illnesses. But government regulators and investigators who have overseen the actions of Assurant and other health insurance companies say it is unprecedented for a company to single out people with HIV.

In his previously undisclosed court ruling, the judge in the Mitchell case also criticized what he said were the company's efforts to cover its tracks.

Assurant Health said that as a matter of policy it did not comment on individual customer claims.

"We disagree with certain of the court's characterizations of Assurant Health's policies and procedures in the Mitchell case," it said in a statement provided by spokesman Peter Duckler, adding: "The case continues to progress through the appellate process."  


Obama Health & The NHS: Patients Trading

Obama & Health: Would you like to move?



Grand Rounds: See First

Sunday, March 28, 2010

Overeating: The Science

In June 24, 2009, I published the following post alerting readers to the combination of 3 simple ingredients that made food “addictive”.

“‘Highly palatable’ foods -- those containing fat, sugar and salt -- stimulate the brain to release dopamine, the neurotransmitter associated with the pleasure center, he found. In time, the brain gets wired so that dopamine pathways light up at the mere suggestion of the food, such as driving past a fast-food restaurant, and the urge to eat the food grows insistent. Once the food is eaten, the brain releases opioids, which bring emotional relief. Together, dopamine and opioids create a pathway that can activate every time a person is reminded about the particular food. This happens regardless of whether the person is hungry.”

Now we have the science! 

Dopamine D2 receptors in addiction-like reward dysfunction and compulsive eating in obese rats
Published  28 March 2010

Lentivirus-mediated knockdown of striatal D2R expression./ Nature Neuroscience
Summary:  We found that development of obesity was coupled with emergence of a progressively worsening deficit in neural reward responses. Similar changes in reward homeostasis induced by cocaine or heroin are considered to be crucial in triggering the transition from casual to compulsive drug-taking. Accordingly, we detected compulsive-like feeding behavior in obese but not lean rats, measured as palatable food consumption that was resistant to disruption by an aversive conditioned stimulus. Striatal dopamine D2 receptors (D2Rs) were downregulated in obese rats, as has been reported in humans addicted to drugs. Moreover, lentivirus-mediated knockdown of striatal D2Rs rapidly accelerated the development of addiction-like reward deficits and the onset of compulsive-like food seeking in rats with extended access to palatable high-fat food. These data demonstrate that overconsumption of palatable food triggers addiction-like neuroadaptive responses in brain reward circuits and drives the development of compulsive eating. Common hedonic mechanisms may therefore underlie obesity and drug addiction

 Girl in a Chemise circa 1905 Pablo Picasso (1881-1973)
Tate Collection


Wednesday, March 24, 2010

Obama Health & The NHS: Patients Trading

President Obama signed major health care legislation into law on Tuesday.
Doug Mills/The New York Times

It would be interesting to see how universal health insurance will pan out in the Obama health care reform.

It made sense that insurers should not be allowed to “cherry pick”. The Cockroach Catcher just realised that perhaps there now will be a new commodity: patients.

The financial world has been about risks and derivatives were designed to minimise risks. All very laudable until some smart ones realise that much money could be made from such instruments.

Health Insurers are a special group of such financial institutions and no doubt they will want to minimise the risks. In the past, it is very simple: exclude risky patients. 


“Insurance companies have long engaged in the practice of ‘rescission,’ whereby they investigate policyholders shortly after they've been diagnosed with life-threatening illnesses.”

It would not have been possible to run the Obama reform without tackling the “cherry picking”. Well by 2014 in any case:

"One of the central reforms of the bill won't start until 2014, when the exchanges open. From then on, insurers will not be able to turn away people with medical problems or charge them more."         The Associated Press

The problem is that you may not be allowed to exclude, but you can certainly devise ways to encourage high risk patients to go to other insurers.


Simple! Money!

As with my parenteral feed patient: pay them to go elsewhere. One insurer paying the patient to go to another one!

It is suddenly very interesting as having a chronic illness or a novel one may become an asset rather than a burden: in other words, it is a new commodity.

At a financial level, re-insurance may become the norm. A sort of “subprime” for Health and of course we all know what happened to the other “subprime”.

At a medical level, it might encourage insurers to offer the best treatments as anything else might prove more expensive.

Of course the unthinkable might happen: patients being paid to go elsewhere.

In England, if Health Insurers cannot “cherry pick”, there is nothing to stop the PCTs (Primary Care Trusts: public bodies that are responsible for funding public patients) insuring NHS patients to limit the cost. 

Who would still want to run Private Health Care then, I wonder! Especially if PCTs insure all their long term medical and psychiatric conditions.

We may get back our NHS!!!

Grand Rounds: See First

Obama & Health: Would you like to move?

Tuesday, March 23, 2010

NHS: Would you like to move?

©2010 Am Ang Zhang
Some years ago, I was asked to see a young boy who required long term parenteral feed. They want to know if he would be able to adjust. He has been moved from London to our beautiful town.

Then I realised that the specially adapted house was all paid for by the health authority in London. It was a bargain at £450,000. The annual cost for his maintenance treatment is estimated at around £1,000,000.

Some very clever people.

With the passing of the
-->health care bill in the US, one must congratulate President Obama for achieving the impossible and he will no doubt be ranked with the greatest presidents.

A few weeks ago, Obama and health reform were doomed and Obama was not up to the job. In the coming days, we will see a jubilant Obama on the cover of newsmagazines. He will be lionized as a giant-killer. His approval ratings will rise, both because more Americans are paying attention to the beneficial features of the bill as opposed to the Republican caricatures and because Americans love a winner.

"And the health bill itself only begins the long task of wresting control of the health care system from callous insurance and drug companies. We still have to fight for a real public option that is the first step towards national health insurance."  
-->Huffington Post

Health Insurers will no doubt be looking for ways to keep the cost down as it is no longer possible with the new US legislation to:

-         Exclude pre-existing conditions
-         Hype premium
-         Exclude patients the following year.

All the above are standard practice in America and Britain for as long as I can remember.
Can the new British Government learn something from these?


On top of that, anyone with insurance seeking NHS treatment, should the cost not be charged to the insurers!!!

Right now, many patients with private insurance are paid a daily rate for using the NHS. The table could be turned.

There is just one problem with the Obama reform: what if one insurer decides to pay for the premium for an expensive patient to go to another insurer.

Would you like to move may take on a new meaning.

Sunday, March 21, 2010

NWHP: Writing Women Back into History

2010 will be the 30th anniversary of the National Women’s History Project

The following is my contribution

In The Cockroach Catcher is a Chapter called “The Peril of Diagnosis”, in which I highlighted three cases where a definitive psychiatric diagnosis was in the end more a hindrance than an aid, as that focused all attention on the cure of the symptoms and little else on the resolution of the underlying psychiatric problems.
........In one of the letters from my contacts at the clinic, I was told that Jane had to be admitted to a hospital in London. Her weight was so low that she was on tube feeding.

News of a famous heiress just flashed through this morning’s news and the psychodynamics of Jane’s Anorexia Nervosa suddenly became clearer. The heiress witnessed her uncle’s murder and was anorectic ever since. Jane was home when her father died in mother’s arms with a massive haemoptysis (coughing up of blood, a rare but not unknown effect of lung cancer, generally a massive bleed). It must have been very traumatic.

How dim of me. That was bereavement, a slow suicide by someone who felt less worthy to survive........

I recently visited the Wellcome Collection for their Madness and Modernity exhibition: about mental illness and the visual arts in Vienna 1900.

It was an interesting experience looking back at “treatment modalities” of mental disturbance in one of the most cultured city in Europe at the start of the 20th Century. There was an ancient Chinese saying: 50 steps laughing at 100 steps – a reference to a deserter who ran 50 steps from a battle field laughing at someone who ran 100 steps. Are any of our present day methods any better than what the Viennese dreamed up over a century ago? At least the mental patients (yes, still patients) then had somewhere specially designed and safe to practise their art and be contained. Will the next generation of psychiatrists laugh at what we are currently practising?

It was no coincidence that right next to the Madness and Modernity exhibition is the show of
Bobby Baker’s Diary Drawings: Mental illness and me, 1997-2008.

Bobby Baker Wellcome Trust

Bobby Baker is a successful performance artist who had suffered acute psychiatric problems including self harming, which she captured over a period of 10 years in hundreds of 'diary drawings'. These paintings (158 drawings, selected from a total of 711) and commentaries demonstrated her anger with the mental health service and any viewer thinking of entering psychiatry might be put off forever.

Bobby was told by the first psychiatrist she saw that she suffered from
borderline personality disorder. (Time article link)
As her story unfolded in her drawings, one gets an uncomfortable feeling about the state of our psychiatric service and wonders if we are even at the 50th step. She has triumphed over some of life’s most frightening experiences despite all.

Bobby Baker Wellcome Collection

“As my ability to function improved, hell became more firmly encased in my skull. I’ve formed the opinion…..that psychosis is a metaphor for extreme suffering. My delusions led to paranoia that a network of professionals was constantly searching for evidence that I was wicked. …….Medication didn’t help – it just made me fatter and fatter.” Bobby Baker Wellcome Collection Exhibition pamphlet.
As a psychiatrist, I could not help being curious about the lack of an early history, having just come from a room showing a replica of Freud’s couch. According to Freud most mental disturbances have roots in one’s early childhood.
The puzzle was solved when I read in the Observer of an interview with her:

“I don't know how but I must ask about her father next - the classic therapist's question is, in her case, inescapable. Again, a picture speaks first. In Telling Keith, she is weeping, her tears bizarrely swirling upwards. Her mouth is open and a sea floods out - in the middle is a tiny, drowning figure. ‘That's my father,’ Baker says. ‘I know,’ I say. I know because, in her autobiographical show Box Story she told audiences about a summer holiday in Brancaster, Norfolk when she was 15 and had just received her surprisingly good O-level results. Telling her father her news was 'the best moment in my life' and he gave her the happiest of hugs. She asked whether he was coming to lunch? Not straight away, he replied. He would have a dip first. A bit later, they heard a woman's voice shouting, ‘Help! Help! Help! A man's been washed out to sea.’ Her mother leapt to her feet shouting, ‘My husband! My husband!’”
Kate Kellaway Observer, Sunday 28 June, 2009.

Like my own patient, Bobby Baker suffered from bereavement.

You won’t be able to see the Madness and Modernity as it has finished, but the Bobby Baker drawings are on show at the Wellcome until the 2nd of August. Those running our psychiatric services should perhaps have a good look as they may well be featuring in a future Wellcome Exhibition.

  Grande Rounds:
Grand Rounds Vol 6, No 26

Slide Show: Guardian.

Can They Draw: From Picasso to Matisse
Picasso, Medicine and Lloyds
Picasso and Tradition

NHS Blog Doctor: Happy Retirement

Happy retirement!

Yellowstone Lake ©2008 Am Ang Zhang

Dr Crippen introduced me in February 2008. Having started blogging after retirement how does one then retire? Mmmmm. 

Thank you. 

Healthcare and the NHS is a big topic but I have said what I have to say and increasingly I am just going round and round the houses. I remain committed to the ideal of a decent standard of healthcare being available to all, independent of means and status. Sadly, we are further away from that ideal than we were five years ago when I started NHS BLOG DOCTOR. I am not optimistic about the future.

Dr Grumble:

Crippen would have loved it

NHS: Radical Options

NHS: Demolition? No! No! No!

NHS-Kaiser Permanente: Integration or Fragmentation?

Jobbing Doctor

Farewell, friend

 “You sometimes feel that you get to know people quite well from reading their writing. One of the best bloggers to grace the blogosphere was John Crippen of NHS Blog Doctor. His writing it was, along with Dr Rant, who persuaded the Jobbing Doctor to start blogging.

Wednesday, March 17, 2010

Photography: Old & New

It was a rather somber day when I gave away all the chemicals that I have accumulated over the years of dark room work. As it happened the couple that got them were both medical doctors. Hopefully they make good use of them.

There is indeed much that modern day software can do to duplicate the work of the traditional dark room. Yet there is something magical seeing your print wet and perfect in the dark room.

I have often been asked about some of my photos:

Here are some of the technical details.

Both are taken with Nikon FM2 180/2.8 ED lens. The lens was probably the best of the hand held pre-digital lens Nikon ever produced and I still use it with my Digital Body. 

Film: Kodak Tmax100 Kodak developer.
Paper: Oriental Seagull (3) FB.
Developed using diluted Kodalith Developer. Further toning using Kodak Selenium toner for enhanced tones.
 ©1995 Am Ang Zhang

New York
Sharp-eyed photographers would notice Pan Am sign thus dating the picture.

Film: Ilford 400 developed by pushed Rodinal developer to get the sharp and huge grains.
Paper: Oriental Seagull (3) FB.
Developed using diluted Kodalith Developer. Further toning using Kodak Selenium toner for enhanced tones.

 ©2008 Am Ang Zhang

It is vital to get the sharp focusing of the grains.

Photoshop can in the quadtone mode assign different tones to different levels at will and the level adjustment will enhance what is often a gamble on Lith. Modern printers cannot quite produce the exhibition quality of good Fibre Base Paper of old.
© Am Ang Zhang 2012

Lith Style Photographic work.