Study: Primary Care May Be Path To More Effective Suicide Prevention

The unanswerable question, “What If?” often dominates the talk when it comes to illness. What if the tumor had been caught earlier; what if the child’s ache taken more seriously? When it comes to suicide, the agonizing “What Ifs?” can run rampant.

Recently, following three suicide deaths by high school students in Newton, Mass. there has been much talk about what, if anything, might have been done to prevent these acts.

A new national study offers no easy answers — indeed, many people who die by suicide do so without any prior mental health diagnosis, researchers report. But this new research does suggest there may be opportunities — through primary care doctors, and other specialists, for instance — to more accurately identify people at risk for suicide, and perhaps intervene before it’s too late.

The new federally-funded study — based on a longitudinal review of more than 5,800 people who died by suicide from 2000 to 2010 — found that nearly all of these individuals (83 percent) saw a doctor or received some kind of health care in the year prior to their death, but half of those individuals did not have a mental health diagnosis. Moreover, researchers report: “Only 24% had a mental health diagnosis in the 4-week period prior to death.”

Also, strikingly, one in every five people who died by suicide “made a health care visit in the week before their death,” says the paper’s lead author Brian K. Ahmedani, Ph.D., assistant scientist in the Center for Health Policy and Health Services Research at Henry Ford Health System in Detroit, who speaks about the work in an accompanying video.

The study, published online in the Journal of General Internal Medicine, concludes that: “Greater efforts should be made to assess mental health and suicide risk. Most visits occur in primary care or medical specialty settings, and suicide prevention in these clinics would likely reach the largest number of individuals.”

Of course, that’s easier said than done. Anyone familiar with a typical primary care visit knows it can be, well, a bit rushed — not quite the perfect venue for dwelling on complicated emotional issues that may be difficult to articulate. Unless specific psychiatric symptoms are raised, they are often not part of routine care, says Massachusetts General Hospital psychiatrist Steven C. Schlozman, Continue reading

New Mass. Challenge: How To Spend $43 Million On Getting Healthier

Ladies and gentlemen of the Massachusetts health sphere, start your mental engines.

As decreed in the state’s latest health reform law, Massachusetts will spend a total of $60 million dollars over the next several years on trying to stop health spending before it happens — by keeping people healthier. Of that $60 mllion total, $43 million goes to competitive grants, and if you’ve got a brilliant idea, you can now apply for one.

I must say, prevention money so often gets short shrift when it comes to health budgets that I’m pleasantly surprised to see that the state’s “Prevention and Wellness Trust Fund” did not fall victim to any sort of fiscal knifery. And I can’t wait to see what people come up with.

The folks at the Massachusetts Public Health Association, which led the effort to create the trust fund, kindly sent over the state document below laying out the basics on the grants. And if you want to actually apply, you must navigate the terrifying jungles of the state procurement system; you can try going to this page and typing “Prevention and Wellness Trust” into the search box. I just tried it and it worked for me (just as a test — we’re not competitors; so if you think your idea is so cool it deserves CommonHealth coverage, give us a yell…)

Massachusetts Prevention and Wellness Trust Fund

· Funding available: $42,750,000 over 4 years

· Goal: to reduce healthcare costs in the Commonwealth by supporting evidence-based community and clinical prevention strategies and providing activities that will simultaneously decrease preventable risk factors and illness and improve the management of existing chronic disease.

· Priority conditions: funded programs must address at least two of the program’s priority positions:
o tobacco use
o pediatric asthma
o hypertension
o falls among older adults Continue reading

Commentary: When Patients Fall Through The Health Coverage Gap

By Dr. Nancy Adams
Guest Contributor

Ms. X has worked hard — and fast — as a barista for years. She’s employed by a company that offers her access to health insurance, but she has never been allowed to work a 40-hour week — an increasing problem in many industries nationwide.

As a poorly controlled diabetic with high blood pressure and cholesterol, Ms. X needs a minimum of six prescription medications. She should also be monitoring blood sugars daily and have lab tests every three to four months.

But because her health insurance requires high out-of-pocket deductibles for medicines, testing strips, and lab tests as well as office visits, she cannot afford to pay for all the recommended care. So her diabetes remains poorly controlled, and that increases her risks of heart disease, peripheral vascular disease, blindness and kidney failure.

Dr. Nancy Adams

Dr. Nancy Adams

As a primary care provider for 30 years in Chelsea, Mass., I have had first-hand experience dealing with all the defects of our current health care system. And I have spent many hours trying to explain to intelligent, interested consumers why it is so flawed. A fundamental problem is that the incentives for the consumer and those for insurers and providers have been misaligned.

The insurer who pays for this year’s health costs for Ms. X, and saves hundreds of dollars by making her pay more out of her own pocket, is unlikely to be the same one who spends many thousands of dollars years from now if she is hospitalized or needs procedures.

If she does develop complications, by the time she is covered by Medicare, she may need care from multiple specialists and many more medications and tests. In a worst-case scenario, she could end up needing hundreds of thousands of dollars in additional care. The old saying “penny wise and pound foolish” certainly applies.

As health costs rise, more and more patients have to pay increasing amounts out of pocket, and this “penny-wise” problem is getting worse. Current annual deductibles for all consumers now average more than $1000 for an individual and more than $2000 for a family nationwide. Continue reading

Overdose Antidote: What The Government Doesn't Do, And What You Can


(PunchingJudy/Flickr Creative Commons)

You hear a lot these days about the national epidemic of painkiller overdoses. What you don’t hear so much about is what you can do to respond to those overdoses when they happen, much as we learn about CPR or defibrillators for heart attacks.

In an opinion piece just out in the Journal of the American Medical Association, Northeastern University assistant professor of law and health sciences Leo Beletsky and his co-authors argue that the government should do far more to enable the public to fight overdoses. Why doesn’t it? And what can each of us do? He explains here.

By Leo Beletsky
Guest contributor

Now a true national crisis, overdose from opioid drugs like Oxycontin and heroin kills about 16,000 Americans every year. Outranking car accidents, it is now the leading cause of accidental death in many states, including Massachusetts.

Rural and poor communities are particularly hard-hit, but contrary to popular belief, this epidemic does not discriminate: Overdose victims come from all classes, races, and age groups. Deaths afflict both legitimate and illicit users of prescription medications as well as those using street drugs like heroin.

Many of these deaths could be averted. Long-term prevention efforts are needed, but in the meantime, there are some straightforward things we can all do immediately to stop overdoses from turning fatal.

First: From the onset of the telltale signs of overdose, such as shallow breathing and slow pulse, it typically takes 30 to 90 minutes for the victim to die. This provides a precious window of opportunity to save a life. The tragic reality is that people often don’t recognize the overdose in time and thus don’t quickly call 911.

Second: Most people do not realize that once an ambulance has been called, they can help save the victim’s life. The key is to determine if the person is breathing; if not, rescue breathing and CPR should be performed. And ideally, the drug naloxone should be given to the victim.

Leo Beletsky

Northeastern University’s Leo Beletsky (Courtesy of Northeastern)

What is naloxone? Known by the brand name Narcan, it is an overdose antidote, a drug whose only effect is to reverse an overdose from opioid drugs like Oxycontin, Vicodin or heroin. Given via injection or nasal spray, it blocks the opioid receptors in the brain, typically working within about four minutes to revive the victim.

It seems like a no-brainer, doesn’t it? Shouldn’t anyone who takes opioids, or who is close to someone who does, know what to do in the event of an overdose, and keep this potentially lifesaving drug available?

In fact, however, it is much harder than it should be to get and fill a prescription for naloxone, even though it’s extremely safe and has no potential for abuse.

Why? Continue reading

Prevention Nation: When Health Care ‘Takes Over’ The Government

It’s an unsung and little-known piece of Obamacare — even though it is beginning to permeate our government, and it aims to permeate our lives (in a nice, non-Orwellian way, that is) and it may be our best hope for reining in the country’s skyrocketing health costs.

It can be summed up in a word: Prevention. To wit: It is far, far better to keep people healthy than to treat them when sick — especially with our staggering rates of chronic disease, such as this week’s statistics on the soaring rates of diabetes. To that aim, thinking about health has to inform government policy across the board — even in agencies that seem to have nothing to do with it.

You’ve likely heard of the free preventive care, from checkups to vaccines, that Obamacare requires. But this gets even bigger than that. Obamacare expert John McDonough of the Harvard School of Public Health calls the prevention piece one of the most visionary and long-term-important parts of the law.

You think, ‘Oh my God, this is an attempt by the health care people to take over the universe,’ but it’s actually the opposite.

“What’s interesting about it,” he said, “is that it is the first major federal effort at crafting an approach that is referred to as ‘health in all policies,'” an international concept for infusing preventive health into all government policies, from transportation to housing to education.

“If you first look at it, you think, ‘Oh my God, this is an attempt by the health care people to take over the universe,’ but it’s actually the opposite,” he said. “It’s an approach that says that by incorporating a preventive health mindset into all of these other domains, you can dramatically decrease the size and cost of health care in the United States.”

“I think this is the future of how we’re going to fix health care,” he said.

He offered an example: The “Green and Healthy Homes Initiative.” The Department of Energy wants to weatherize the nation’s homes, but in many low-income neighborhoods, sealing in the heat also seals in triggers of asthma, lead poisoning and high blood pressure. So if the unhealthy factors are fixed at the same time, you lower not only energy costs but medical costs. “The health people, housing people and energy people working together: That’s a ‘health in all policies’ approach,” he said. “That’s what the national prevention strategy is all about.”

If this country did royalty and we had a Queen of Prevention, that would be Dr. Regina Benjamin, the surgeon general of the United States and thus “America’s doctor.” (No, it’s not Mehmet Oz.) She leads the new National Prevention Council created under Obamacare, and was recently in Boston to receive an award from the health policy institute NEHI. Our conversation, lightly cut and edited: Continue reading

But Will The Cost-Cutting Bills Really Save Money?

It may not rank at the tippy-top of the titillation scale, but this thoughtful discussion about reining in health care costs featuring Brian Rosman of Health Care For All, and Joshua Archambault of The Pioneer Institute, covers some key issues in the House and Senate cost-cutting proposals now pending in the Legislature.

The plans are estimated to save about $150 billion over 15 years, but Archambault calls the proposals “faith-based initiatives,” when it comes to savings projections. That’s because he says it remains unclear if the new focus on prevention and wellness and the new payment models will actually save money.

“If we change the way we pay for health care and if we change the way we deliver health care, will we save money?” Archambault asks in the CommonWealth magazine “Face to Face” video conversation. He says there’s really no proof that these models will lead inexorably to savings. Continue reading

Study: Consumers With ‘Skin In The Game’ May Have Lower Health Costs But Risks Remain


At some point we will all be paying a greater share of our health costs. This is inevitable even for those of us who now blithely float from one provider to the next essentially unaware of what our medical care costs because beyond our insurance premiums, we don’t pay for most of it. When we have more ‘skin in the game’ as health economists like to say, we may finally become more engaged.

A new study by the RAND Corporation bears this out. It concludes that when consumers have the kind of health insurance that requires more out-of pocket payments, they do, indeed, become more mindful of their care. And this more conscious approach to picking and choosing medicines, tests, specialists and treatment could save billions annually, the report, published in the May edition of the journal Health Affairs notes. But these so-called “consumer-directed” health plans, notably high-deductible plans and personal health accounts, do have risks because people may forego important prevention and treatment measures in order to cut costs.

“The study found that among families enrolled in consumer-directed health plans, about two-thirds of the savings were the result of fewer encounters with health care providers. The remaining third was caused by lower spending per encounter, suggesting patients were making different choices about tests and treatments. Families in consumer-directed plans used fewer brand-name drugs, had fewer visits to specialists and had fewer elective hospital admissions than families in traditional plans,” the news release says. Continue reading

Report: U.S. Cancer Screening Is Pricey, But With No Better Outcomes Than Public System

Is more screening worth the money?

A new report comparing cancer screening programs in the U.S. and the Netherlands comes up with this not-so-surprising conclusion: we screen more here — three to four times more in this case — but mortality rates are the same in both countries.

The analysis of cervical cancer screening programs, published in the Milbank Quarterly, makes the health system in the Netherlands look pretty darn rational. Not only does the publicly-run system focus on prevention, but it appears to implement its prevention plan in a way that saves money without undermining care, notably it limits cervical cancer screening to the group at highest risk, women between the ages of 30 and 60.

Here’s are some of the study details from the news release:

The team [led by by Dr. Martin L. Brown from the National Cancer Institute in the United States, alongside colleagues from the Erasmus MC University Medical Center in Rotterdam] focused on cervical cancer screening, which accounts for a small fraction of overall health care spending, but represents broader preventive health services. For comparison the authors carried out a cross-national study of cervical cancer screening intensity and mortality trends in the United States and the Netherlands.

The team used national cancer incidence and mortality data from both the United States and the Netherlands to estimate the number of Pap smears and the cervical cancer mortality rate since 1950. Their results revealed that even though three to four times more Pap smears per woman were conducted in the United States than in the Netherlands over a period of three decades, the two countries’ mortality trends were similar.

Five-year coverage rates for women aged thirty to sixty-four were comparable between the countries at 80 to 90 percent. However, because screening in the Netherlands was limited to ages thirty to sixty, screening rates for women under thirty and over sixty were much higher in the United States. Continue reading

Surgeon General To Speak at Harvard On National Prevention Strategy

Marking my calendar, thought you might like to as well. Doctors for America sent over an invitation to hear the U.S. Surgeon General, Dr. Regina Benjamin, speak at Harvard Medical School on March 21 about the national prevention strategy (Did you know we had one?) as it nears its first anniversary. All health care professionals are welcome and admission is free but you need to register in advance here.

In her recent speech at TEDMED above, Dr. Benjamin recalls that her immediate family could not attend the White House press conference at which President Obama announced her appointment, because her brother had died of HIV, her mother died of lung cancer a year later, and a few years later her father died of complications of a stroke. “All preventable diseases. And so I hope that other family members don’t have to  suffer through the loss of family members,” she says.

From Doctors For America:

In June 2010, Dr. Benjamin unveiled the nation’s first National Prevention Strategy – a roadmap for increasing the number of Americans who are healthy at every stage of life. The NPS recognizes that everyone – health care providers, businesses, educators, government, and communities – have a role to play in transforming our communities into forces for health promotion. Continue reading

Lurching Toward Diabetes: What To Do Before The Sugar Hits

This Friday, the story and legacy of sweetness comes to the stage.

The new one-woman show Sugar, starring Robbie McCauley, breathes life into the sugar trade, slavery, racism and McCauley’s own struggle with diabetes.

Diabetes 101

In fact, a colloquial name for diabetes is “sugar”—appropriate, as the disease is characterized by having high levels of sugar in your blood.  Nowadays, diabetes often goes hand-in-hand with the word epidemic: 25.8 million Americans are diabetics — about 1 in 8 people (1 in 4 for those 65 or older).

McCauley suffers from the less common form, Type 1 diabetes, which accounts for about 5% of all cases. Her body produces little or no insulin (the hormone that enables sugar in the blood to enter the cells which, in turn, use it for energy). The majority of diabetics in America suffer from Type 2 diabetes, which is when your body doesn’t respond correctly to insulin (called insulin resistance) or doesn’t produce enough insulin. Type 2 diabetes disproportionately affects African-Americans, Continue reading