what the what?!?

A recent New York Post article begins with the provocative assertion that "It now costs more to buy health insurance than it does to rent a two-bedroom apartment in the Financial District."

The article then goes on to discuss the rise in health care costs for New York City dwellers in the past year. According to the newspaper's analysis, the average monthly premium has risen 13% since April 2008; then, the average family paid $3,866 per month, now, they pay $4,354. That, according to the Post, "exceeds the $3,947 monthly rent for a place in a no-doorman building downtown."

The Post breaks down the rise by insurance company; the company that raised its rates the most was GHI HMO select, whose out of network fees went up 35%, followed by Aetna, who raised rates 27%. Rates should go up even more, the article says, since companies are expected to pass along an $853 million dollar insurance-related tax in this year's state budget. The Post also noted that there are fewer insurers in New York now than in the past; in 2004, thirteen companies offered insurance in NYC, now eight do.

Finally, the cheery article noted that things will almost certainly get worse before they get better, since more and more New Yorkers are opting out of health insurance, leaving the pool of contributors smaller and sicker.

Blerg.

new bill to try to change HIV testing practices in NYS

On April 16, 2009, a new bill was introduced into the NYS Assembly arguing for a new HIV testing MO in the state of New York. The bill would require that HIV testing "to be part of a signed general consent to medical care" signed by the patient. The bill would also require that all EDs, hospitals, and doctor's offices offer HIV tests to patients on a regular basis, with some very limited exceptions (ie, they are being treated for a life-threatening illness at the time of their visit.)

But what does it mean for the HIV test to be "part" of a "signed general consent"? In an article published April 12, The Albany Democrat and Chronicle interpreted it to mean that patients "would check a box on a general medical-consent form, which would remain in force."

Advocates say that this is still too much of a barrier. C. Virginia Fields, chief executive officer and president of the National Black Leadership Commission on AIDS, is quoted in the Democrat: "What we're saying is routine testing is when you go to a doctor and get a blood work-up, and HIV should be among those (illnesses) tested."

I'm all for lowering barriers to testing for HIV, and myself have recommended several HIV (and chlamydia and herpes and gonorrhea) tests to several patients during my NP clinicals. However, I have trouble picturing HIV being added to "routine testing" because there is no such thing. That is, when a patient turns up at a clinician's office, either perfectly healthy and there for their annual exam, or with a looong list of episodic complaints, the clinician decides what tests to order based on the patient's characteristics. Admittedly, there are some tests (complete/basal metabolic panel, complete blood count, urinalysis) that are ordered for basically everyone, but these are not for diseases as such; they test organ function and indicate disease if abnormal. All of this is to say: in the absence of true "routine tests" for disease, a bill like this one is the only way to improve testing rates via legislation. Unless of course, the legislature wants to mandate that clinicians verbally offer the test for HIV to everyone on every visit. (Come to think of it, that's not a bad idea.) In the meantime, get tested.

Finally, an editorial from the NYT advocating greater awareness of HIV in the US, and more frequent testing for the disease.

exciting step in the right direction

Woot.

The article mentions PEPFAR, which the Washington Post also did an editorial on recently.

wide county by county variation in medicaid denials

Last Thursday the Rockefeller Institute of Government published a report on the county by county variation in denials of applications for Medicaid funding of long term care. Individuals in New York are eligible for Medicaid funding for nursing home care if they make less than $8,700 per year, and if their total assets are less than $13,500, not including their home. Federal law prohibits the transfer of assets by the elderly for five years prior to applying for Medicaid nursing home benefits; obviously the intention of the law is to prevent people would could afford a nursing home on their own from filing for benefits after giving their money family member, friend, etc. so they could access it later. The report, which analyzed the state's 57 counties outside New York City, studied the rate at which Medicaid benefits are denied because of a reported asset transfer.

In the last decade, 7% of the applications for Medicaid benefits for long term care have been denied on the basis of a recent asset transfer. However, the rate at which applications are denied varies wildly from county to county. Some of the counties that deny with the most frequency are: Rockland (24.2%), Ulster (22.6%), Saratoga (14.6%), and Suffolk (14.5%). Some that deny the least are: Westchester (0.5%), Duchess (1.0%), Schenectady (1.2%), Rensselaer (1.3%), Orange (1.4%), and Erie (2.1%). The report offered no opinion as to why the variation exists, but the authors did note their suspicion that the illegal asset transfers are underdetected.

New York has one of the most generous Medicaid programs in the country; in 2006, 42% of the $18.9 billion the State spent on Medicaid went to funding long term care.

report on health care workforce

The Center for Health Workforce Studies, at the University at Albany's School of Public Health, recently published a 136 page study of the health care workforce in New York. The report, which includes a section devoted to NYC, has some fascinating stuff: between 1990 and 2007, the health care workforce of NYC grew by 29%, whereas the workforce of NYC as a whole grew by 16% during the same period. Almost all of the jobs were in the private sector; private hospital jobs increased 3% while public hospital jobs went down 4%. (Hospitals provide about 50% of NYC's healthcare jobs.) Interestingly, the study reports that the number of RN positions in NYC went up 18.9% between 2002 and 2007, while the number of RNs increased only 3.1% between 2003 and 2007. The number of NPs went up 27% between 2003 and 2007. (Good luck with that job search, Laura.)

Overall, the study projects that there will be openings for nearly every type of healthcare job in NYC from 2006-2016. However, recent events have indicated that for RNs, and I would imagine other healthcare workers as well, the the picture has changed dramatically thanks to the recession.

Another unsurprising finding of the study is that minorities are underrepresented in New York State's physician workforce, even as the nonwhite portion of NYS' population continues to grow. Physicians who come from racial minorities are more likely to work in underserved communities and have on average a higher percentage of Medicaid patients.

no kidding

Interesting article Sunday in The Washington Post about how the recession has temporarily made the nursing shortage a thing of the past. Unsurprisingly, nurses are delaying retirement or returning to the workforce in an effort to stay afloat financially, which means even experienced nurses are having trouble finding work. Nursing advocates say this is obviously just a band-aid on the nursing shortage, and continue to urge legislators to consider measure that will alleviate the shortage when it reappears once the recession is over.

Anecdotal evidence from myself and my classmates (we graduated with our BSNs in May 2008) suggests this started to hit NYC last year. I applied to about a dozen hospitals late last summer and early fall, and although I was hired three times, in two cases a hiring freeze twice prevented me from taking the spot. (The third time there was an administrative mix-up.) I was not alone among my classmates in struggling to find work; many people were saying they couldn't even get interviews. Given the number of health sector lay-offs in the city in the past year, none of this is too surprising.

mrsa!

In clinical last Thursday I had the pleasure of seeing my very first suspected MRSA! MRSA is strain of staphylococcus aureus that is resistant to a standard antibiotic, methicillin, as well as other commonly used antibiotics such as penicillin, oxacillin, and amoxicillin. MRSA has been around NYC for some time now , and recently has been seen more and more in children; daycare facilities have been cited as places the infection can spread rapidly.

Prior to the past five years, MRSA was rarely seen outside the hospital, and infections were predominately found in immunocompromised people. However, since then, community acquired infections (CA-MRSA)have increased dramatically, and crowded cities like NYC have seen the biggest rate of infection. MRSA can linger in the nose, blood, urine, and on the skin. Generally the infection is transmitted among people who share personal items (razors, towels, athletic equipment). CA-MRSA typically manifests as boils or pimples.

Which brings me back to my patient. He presented with an abscess that had been pimple-like less than 48 hours ago, but in that short period had expanded into a one inch in diameter abscess surrounded by a large, reddened, indurated area about 3" by 5". My preceptor told me MRSA's nicer cousin, methicillin-suseptible staphylococcus aureus (MSSA), usually presents as a nice clean abscess you can drain without difficulty. MRSA, she said, presents like this: a hardened area where much of the pus has seeeped into the surrounding tissue. Think of it as the difference between using a needle to pop a water balloon vs using one to drain a sponge, she told me. Great. We gave him some Lidocaine and drained what we could before sending him off with Bactrim and the specimen to the lab. Fun update: the culture came back MSSA. Ah, well.

nyc anti-smoking campaign began yesterday

The NYC Department of Health and Mental Hygiene is hitting smokers where it hurts : by reminding them what smoking can do to their kids. The Department has developed two ads, based on Australia's Quit Victoria campaign, that depict how a parent's smoking habit can affect children. One of the ads features information on the side effects assoicated with secondhand smoke: asthma, pneumonia, ear infections. The campaign is called "Cigarettes are Eating You and Your Kids Alive". The second ad features a lost (and adorable) kid panicking as he looks for his parents. A voiceover features the comment: “If this is how your child feels after losing you for a minute, just imagine if they lost you for life.” Ouch.

The ads will run for about two weeks in both English and Spanish. The City Health Commissioner points out that about 400,000 smoking New Yorkers live wiht a child, and that about 8,000 New Yorkers die each year from smoking.