Consumers May Have More Control Over Health Costs Than Previously Thought

The historic RAND Health Insurance Experiment found that patients had little or no control over their health care spending once they began to receive a physician's care, but a new study shows that this has changed for those enrolled in consumer-directed health plans.

Patients with health coverage that includes a high deductible and either a health savings account or a health reimbursement arrangement reduced their costs even after they initiated care.

Overall, the study found about two thirds of the reduction in total health care costs was from patients initiating care less often and the remaining third was from a reduction in costs after care is initiated. The findings were published online by the journal Forum for Health Economics and Policy.

"Unlike earlier time periods, it seems that today's consumers can have greater influence on the level and mix of medical services provided once they begin to receive medical care," said Amelia Haviland, the study's lead author and a senior statistician at the RAND Corporation, a nonprofit research organization. "We found that at least part of the savings in cost per episode reflects choices for less-costly treatments and products, not just a reduction in the number of services."

Researchers from RAND, Towers Watson and the University of Southern California examined the claims experience of many large employers in the United States to determine how consumer-directed health plans and other high-deductible plans can reduce health care costs. The study was funded by the California HealthCare Foundation and the Robert Wood Johnson Foundation.

According to Haviland, at least three factors influenced the cost of care once the patient had initiated care: lower use of name-brand medications, less in-patient care and lower use of specialists. Researchers speculate that patients may talk to their doctors about their higher deductibles and ask them to help keep costs low.

"It is not surprising that deductibles of $1,000 or more reduced health care consumption, but we found that savings occurred even when employers helped employees offset these out-of-pocket costs by making contributions to their accounts," said Roland McDevitt, a study co-author and director of health research at Towers Watson, a human resource and employee benefits consultancy. "This was true for both health savings accounts and health reimbursement arrangements."  

Health reimbursement arrangements and health savings accounts create different incentives for employees. Health reimbursement arrangements allow employers to pay for qualified medical expenses, including those that fall under the deductible. These payments or reimbursements are excluded from the taxable income of the employee. Unused portions may roll over at the end of the year, but any account balance is owned by the employer and employees generally forfeit the account balance if they leave the employer before retirement.

Health savings accounts create a stronger incentive for employees to manage their health care costs, because the employee owns the account. This type of account was shown to have the largest impact on cost reductions. It can earn interest and it follows employees when they change jobs.

Health savings account contributions are only allowed for those enrolled in high-deductible health plans as defined by law, but account balances may be used for qualified medical expenses at any time. The minimum health savings account deductibles for 2011 are $1,200 for single coverage and $2,400 for family coverage.

The study found that both the level of the deductible and the level of the employer account contributions influence the extent of savings. Higher deductibles of $1,000 or more together with employer account contributions of less than half the deductible produced the greatest cost reductions. 

"It is clear that high-deductible health plans with personal medical accounts produce overall health care cost savings and not simply a cost shift," said co-author Neeraj Sood, associate professor at the Schaeffer Center for Health Economics and Policy at USC and a RAND economist. "This is mostly due to patients initiating less care, but a full third of the reduction is due to shifts in the mix of care they are receiving."

The authors cautioned that there was some reduction in the rate of cancer screenings and childhood immunizations during the first year of enrollment in a high-deductible plan. They found this first-year effect was relatively small, but expressed concern about the early trend. They say more research is needed to determine the extent to which these cost reductions come at a price of forgoing necessary medical care.  

US Scores 64 Out Of 100: Commonwealth Fund Commission National Health Care Scorecard

The U.S. health care system scored 64 out of 100 on key measures of performance, according to the third national scorecard report from the Commonwealth Fund Commission on a High Performance Health System, released today. The scorecard finds that - despite pockets of improvement - the U.S as a whole failed to improve when compared to best performers in this country, and among other nations. The report also finds significant erosion in access to care and affordability of care, as health care costs rose far faster than family incomes.

At the same time, the scorecard highlights some bright spots for the U.S., with notable gains in quality of care in areas that have been the focus of public reporting or collaborative improvement initiatives. For example, 50 percent of adults with high blood pressure had it under control in 2007-2008, compared with only 31 percent in 1999-2000. In addition, hospital quality indicators for treatment of heart attack, heart failure, and pneumonia, and prevention of surgical complications, have improved substantially across the country since hospitals began publicly reporting their quality data through a federal website.

The report, Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2011, measures the U.S. health care system across 42 key indicators of health care quality, access, efficiency, equity, and healthy lives. The scorecard compares U.S. average performance to rates achieved by the top 10 percent of U.S. states, regions, health plans, hospitals or other providers or top-performing countries. The 2011 score of 64 was slightly below the overall score of 67 in the first national scorecard published in 2006, and the score of 65 in the second scorecard, in 2008. The authors note that latest data in the scorecard primarily fall between 2007 and 2009, before enactment of the Affordable Care Act. They point out that provisions in the new law target areas for improvement where the U.S. falls short, particularly in access to care, affordability of care, and support for more patient-centered, coordinated care.

"If we target areas where we fall short and learn from high-performing innovators within the United States, we should see significant progress in the future," said Commonwealth Fund Commission Chair David Blumenthal, M.D., Samuel O. Thier Professor of Medicine and Professor of Health Care Policy at Massachusetts General Hospital/Partners HealthCare System and Harvard Medical School. "The Affordable Care Act and investments in information systems offer the potential for rapid progress in areas like adoption and use of health information technology, safer care, and premature deaths from preventable complications." 

The scorecard finds that the U.S. is failing to keep up with gains in health outcomes made by other countries: the U.S. ranks last out of 16 countries when it comes to deaths that could have been prevented by timely and effective medical care. If the U.S could do as well as the leading country, as many as 91,000 fewer people would die prematurely every year.
Quality Initiatives Showing Promise

According to the scorecard, public reporting of quality data on federal Web sites and collaborative initiatives, like the Advancing Excellence nursing home improvement campaign and Premier hospital quality initiatives, have resulted in substantial and rapid improvements on some quality indicators. For example:
  • The proportion of home health care patients who gained improved mobility grew from 37 percent to 47 percent from 2004 to 2009.
  • 96 percent of hospitals reported providing the right care to prevent surgical complications in 2009, up from 71 in 2004.
Despite these improvements, quality of care still varies widely across the country. For example, despite a 13 percent drop in hospital admissions for heart failure and pediatric asthma from 2004 to 2007, rates vary twofold to fourfold across states.

"This scorecard illustrates that focused efforts to change the health care system for the better are working and are worth our investment," said Maureen Bisognano, President and CEO of the Institute for Healthcare Improvement, and a Commonwealth Fund Board and Commission member. "Yet, the U.S. still spends up to twice as much on health care as other high-income countries, but too often fails to deliver what people need - timely access to high quality, efficient health care. The places in the U.S. and around the world that set the benchmarks prove that it is possible to do better."

Failing To Improve

Despite some quality improvements, the scorecard finds that in many areas U.S. health system performance has either failed to improve, or declined over time.

Steep Decline in Access and Affordability

Access to health care and health care affordability stand out for how quickly and significantly they deteriorated. By 2010, 81 million adults - 44 percent of all adults under age 65 - were either underinsured or uninsured at some point during the year - up from 61 million in 2003. For those with insurance, premiums rose far faster than incomes. In 2003, a majority of people (57 percent) lived in a state where health insurance premiums averaged less than 15 percent of average (median) incomes. By 2009, only four percent of the population lived in such states. In addition, by 2010, 40 percent of working-age adults had medical debt or faced problems paying medical bills up from 34 percent in 2005.

Broad Evidence of Inefficient Care

The U.S. also does particularly poorly on measures of health system efficiency, scoring only 53 out of a possible 100. This area of the scorecard includes such issues as evidence of duplicative services, high rates of hospital readmissions, relatively low use of electronic information systems, and high administrative costs. This low score translates into significant costs to the health care system. For example, the scorecard finds that the U.S. could save $55 billion a year if it could lower insurance administrative costs to the average of administrative costs in other countries with mixed public-private insurance systems.

Other areas of concern include:
  • Primary care and preventive care: Forty-four percent of adults report that they didn't have an accessible primary care provider in 2008, and only half of adults received all recommended preventive care - which is on par with what was reported in the 2006 Scorecard.
  • Childhood obesity: Childhood obesity rates are high, with about one-third (32%) of children ages 10 to 17 overweight or obese, ranging from one-quarter to 39 percent between the top and bottom five states.
  • Infant mortality: The average U.S. infant mortality rate is more than 35 percent higher than the rates achieved in the best states, and rates in even the best states are twice as high as those in other countries.
  • Safe care: One-quarter of elderly Medicare beneficiaries were prescribed a potentially inappropriate drug.
  • Rehospitalizations: Rehospitalization rates failed to improve and varied widely, with 20 percent of Medicare patients hospitalized for certain conditions or procedures readmitted within 30 days in both 2003 and 2009. Rates in the highest-rate regions were 50 percent higher than in the lowest-rate regions.
Potential for Improvement

The scorecard identifies pockets of high performance which illustrate the potential for the nation if others could learn from these high performers. Improvements would add up to significant gains in lives and dollars saved. For example, if the entire nation could do as well as the top performers:
  • Thirty-eight million more adults would have a primary care doctor and 66 million more would receive all recommended preventive care.
  • Reducing health insurance administrative costs to the average level achieved in countries with mixed private-public insurance systems, like the U.S., would save $55 billion a year. Achieving benchmarks of the best countries would save an estimated $114 billion a year.
  • Up to 91,000 fewer people would die before age 75 each year of conditions amenable to health care, include screenable cancers, diabetes, and infections.
Moving Forward: The Affordable Care Act

The Affordable Care Act will lay the groundwork for wider reforms by providing all families access to affordable and comprehensive health insurance regardless of where they live. The report notes that access to insurance is "the essential foundation for improvement" as access, health care quality, and efficiency are interrelated. In addition, the Affordable Care Act includes reforms that seek to strengthen primary care, improve care coordination, invest in prevention, and to ensure access to high quality care that focuses on improving health.

"Health care reform is already beginning to improve health system performance by expanding access to care, reducing administrative costs in health insurance, and piloting projects that could improve health care quality and achieve savings," said Commonwealth Fund President Karen Davis. "This year's scorecard makes it clear that changes in the Affordable Care Act designed to reduce waste, cut costs and help people afford the care they need are on target. The health and future economic security of the country depend on moving forward with these crucial reforms."

Health Insurance Doesn't Always Protect People From Medical Debt

In 2010, about 40 percent of Americans-or 73 million people-had trouble paying medical bills, up from 34 percent in 2005. Now, a new study confirms that having health insurance coverage is no guarantee against accumulating medical debt for working-age adults. Not surprisingly, the study likewise finds that both medical debt and lack of insurance coverage lead to reduced access to health care.

"We think of insurance as protecting us from unexpected large financial impact. We have car insurance, house insurance and other kinds of insurance for that reason," said Patricia Herman, lead study author and an economist at the University of Arizona. "There is an expectation that if you have health insurance that you are protected from being financially devastated by illness or injury. Unfortunately, this isn't always the case."

The study, which appears online and in the August issue of the American Journal of Public Health, used data from the 2008 Arizona Health Survey of 4,200 state households. The survey included items about whether households were having trouble paying medical bills, if participants had delayed or not obtained medications or other needed medical care and whether participants had chronic health conditions. It also asked questions about household income, ethnicity and health insurance status.

The study focused on adults, ages 19 to 64, as those 65 and older have access to Medicare.

Although 83 percent of Arizonians have health insurance, nearly 27 percent of insured households reported problems paying medical bills or currently were paying medical bills. For those who had been uninsured in the past year but who now had coverage, 43 percent reported difficulties paying medical bills.

In addition, households reporting either medical debt or inconsistent coverage were five to six times as likely to delay filling prescriptions or getting needed health care, the study found, compared to those households that were without medical debt and with consistent insurance coverage.

Sara Collins, an economist and vice president for Affordable Health Insurance at the Commonwealth Fund, a philanthropic organization devoted to increasing access to care, commented on these findings. "If you have gaps in your health insurance, you're more likely to have problems paying your medical bills than someone who is insured all the time," Collins said. "The study underscores the need to make sure people have smooth transitions when they lose a job or when their income changes." Collins is not associated with the study.

Medical debt in patients with health insurance is often due to high out-of-pocket expenses, such as coinsurance, deductibles and annual and lifetime dollar limits. In addition, lost wages due to an inability to work often accompany medical debt, higher credit card debt and increased bankruptcy rates.

"In this country, health insurance is most commonly tied to our jobs, so you can lose your insurance status," Herman said. "It's such a double whammy to be hit by that when you're sick."

Collins predicts that the Affordable Care Act will provide relief for many people with inconsistent or incomplete insurance coverage, especially households with lower incomes. However, she says, "It will be really important for policy makers to ensure that people will be protected from high out-of-pocket costs as the law is implemented."

Terms Of Use: This story is protected by copyright. When reproducing any material, including interview excerpts, attribution to the Health Behavior News Service, part of the Center for Advancing Health, is required.

Herman PM, Rissi JJ, Walsh ME. Health insurance status, medical debt, and their impact on access to care in Arizona. Am J Public Health 101(8), 2011.

Health Behavior News Service 

Why quit smoking?

Nicotine is a very addictive drug. People usually try to quit many times before they are successful. But the struggle can be worth the effort. In September 1990, the US Surgeon General outlined what you gain when you quit smoking:
  • Quitting smoking has major health benefits that start right away. This is true for people who already have a smoking-related disease as well as those who don't.
  • Former smokers live longer than people who keep smoking. For example, people who quit smoking before age 50 have one-half the risk of dying in the next 15 years compared with people who keep smoking.
  • Quitting smoking lowers the risk of lung cancer, other cancers, heart attack, stroke, and chronic lung diseases such as emphysema and chronic bronchitis.
  • Women who stop smoking before they get pregnant, or even during the first 3 to 4 months of pregnancy, reduce their risk of having a low birth-weight baby to that of women who never smoked.
  • The health benefits of quitting smoking are far greater than any risks from the weight gain or any emotional or psychological problems that may follow quitting.
Your risk of having lung cancer and other smoking-related cancers depends on how much you have been exposed to cigarette smoke over your lifetime. This is measured by the number of cigarettes you smoked each day, how you smoked them, how young you were when you started smoking, and the number of years you have smoked. There is no way to precisely measure a person's risk of getting cancer, but the more you smoke and the longer you do it, the greater your risk.
The good news is that the risk of having lung cancer and other smoking-related illnesses can be reduced if you stop smoking. The risk of lung cancer is less in people who quit smoking than in people who keep smoking the same number of cigarettes every day. The risk decreases as the number of years since quitting increases.
People who stop smoking while they are young get the greatest health benefits from quitting. Those who quit in their 30s may avoid most of the risk due to tobacco use. But even smokers who quit after age 50 largely reduce their risk of dying early. The argument that it is too late to quit smoking because the damage is already done is not true. It is never too late to quit smoking!
For more information, see our Guide to Quitting Smoking.

What is in tobacco?

Cigarettes, cigars, and spit and pipe tobacco are made from dried tobacco leaves, as well as ingredients added for flavor and other reasons. More than 4,000 different chemicals have been found in tobacco and tobacco smoke. Among these are more than 60 chemicals that are known to cause cancer (carcinogens).
Many substances are added to cigarettes by manufacturers to enhance the flavor or to make smoking more pleasant. Some of the compounds found in tobacco smoke include ammonia, tar, and carbon monoxide. Exactly what effects these substances have on the cigarette smoker's health is unknown, but there is no evidence that lowering the tar content of a cigarette lowers the health risk.
As of now, cigarette manufacturers are not required to give out information to the public about the additives used in cigarettes, which has made it harder to determine their possible health risks. But with the passage of a new federal law, manufacturers must submit lists of ingredients to the Food and Drug Administration (FDA) starting in 2010. The FDA will make lists of harmful ingredients available to the public by or before June 2013.

Nicotine addiction

Addiction is marked by the repeated, compulsive seeking or use of a substance despite its harmful effects and unwanted consequences. Addiction is defined as mental and emotional dependence on the substance. Nicotine is the addictive drug in tobacco. Regular use of tobacco products leads to addiction in many users.
In 1988, the US Surgeon General concluded the following:
  • Cigarettes and other forms of tobacco are addicting.
  • Nicotine is the addicting drug in tobacco.
  • The ways people become addicted to tobacco are much like those that lead to addiction to other drugs such as heroin and cocaine.
These statements are as true today as they were then. All forms of tobacco have a lot of nicotine. It is easily absorbed through the lungs with smoking and through the mouth or nose with oral tobacco (spit, snuff, or smokeless tobacco). From these entry points, nicotine quickly spreads throughout the body.
Tobacco companies are required by law to report nicotine levels in cigarettes to the Federal Trade Commission (FTC). But in most states they are not required to show the amount of nicotine on the cigarette package label. The actual amount of nicotine available to the smoker in a given brand of cigarettes is often different from the level reported to the FTC. In one regular cigarette, the average amount of nicotine the smoker gets ranges between about 1 mg and 2 mg. But the cigarette itself contains more nicotine than this. The amount people actually take in depends on how they smoke, how many puffs they take, how deeply they inhale, and other factors.

How powerful is nicotine addiction?

About 70% of smokers say they want to quit and about 40% try to quit each year, but only 4% to 7% succeed without help. This is because smokers not only become physically dependent on nicotine; there is a strong emotional (psychological) dependence. This is what leads to relapse after quitting. The smoker may link smoking with social and many other activities. Smokers also may use cigarettes to help manage unpleasant feelings and emotions, which can become a problem for some smokers when they try to quit. All of these factors make smoking a hard habit to break.

Cigarette Smoking

Cigarette Smoking

The 1982 United States Surgeon General's report stated that "Cigarette smoking is the major single cause of cancer mortality [death] in the United States." This statement is as true today as it was then.
Tobacco use is responsible for nearly 1 in 5 deaths in the United States. Because cigarette smoking and tobacco use are acquired behaviors -- activities that people choose to do -- smoking is the most preventable cause of death in our society.
Here is a brief overview of cigarette smoking: who smokes, how smoking affects health, what makes it so hard to quit, and what some of the many rewards of quitting are. For more on these topics, see our Guide to Quitting Smoking.

Who smokes?


The Centers for Disease Control and Prevention (CDC) reported that more than 46 million US adults were current smokers in 2009 (the most recent year for which numbers are available). This is 20.6% of all adults (23.5% of men, 17.9% of women) -- about 1 out of 5 people.
When broken down by race/ethnicity, the numbers were as follows:
    African Americans
    American Indians/Alaska Natives
    Asian Americans
    People of multiple races
There were more cigarette smokers in the younger age groups. In 2009, the CDC reported 24.% of those 25 to 44 years old were current smokers, compared with 9.5% of those aged 65 or older.

High school and middle school students

Nationwide, 20% of high school students were smoking cigarettes in 2009. The most recent survey of middle school students shows that about 5% were smoking cigarettes. In both high schools and middle schools, white and Hispanic students were more likely to smoke cigarettes than other races/ethnicities. (For more information, see our document, Child and Teen Tobacco Use.)
What kinds of illness and death are caused by smoking?
About half of all Americans who keep smoking will die because of the habit. Each year about 443,000 people in the United States die from illnesses related to tobacco use. Smoking cigarettes kills more Americans than alcohol, car accidents, suicide, AIDS, homicide, and illegal drugs combined.

Cancer caused by smoking

Cigarette smoking accounts for at least 30% of all cancer deaths. It is linked with an increased risk of the following cancers:
  • Lung
  • Larynx (voice box)
  • Oral cavity (mouth, tongue, and lips)
  • Pharynx (throat)
  • Esophagus (tube connecting the throat to the stomach)
  • Stomach
  • Pancreas
  • Cervix
  • Kidney
  • Bladder
  • Acute myeloid leukemia
Smoking is responsible for almost 9 out of 10 lung cancer deaths. Lung cancer is the leading cause of cancer death in both men and women, and is one of the hardest cancers to treat. Lung cancer is a disease that can often be prevented. Some religious groups that promote non-smoking as part of their religion, such as Mormons and Seventh-day Adventists, have much lower rates of lung cancer and other smoking-related cancers.

Other health problems caused by smoking

As serious as cancer is, it accounts for less than half of the deaths related to smoking each year. Smoking is a major cause of heart disease, aneurysms, bronchitis, emphysema, and stroke.
Using tobacco can damage a woman's reproductive health and hurt babies. Tobacco use is linked with reduced fertility and a higher risk of miscarriage, early delivery (premature birth), and stillbirth. It is also a cause of low birth-weight in infants. It has been linked to sudden infant death syndrome (SIDS), too.
Smoking can make pneumonia and asthma worse. It has been linked to other health problems, too, including gum disease, cataracts, bone thinning, hip fractures, and peptic ulcers. Some studies have also linked smoking to macular degeneration, an eye disease that can cause blindness.
Smoking can cause or worsen poor blood flow in the arms and legs (peripheral vascular disease or PVD.) Surgery to improve the blood flow often doesn't work in people who keep smoking. Because of this, many surgeons who work on blood vessels (vascular surgeons) won't do certain surgeries on patients with PVD unless they stop smoking.
The smoke from cigarettes (called secondhand smoke or environmental tobacco smoke) can also have harmful health effects on those exposed to it. Adults and children can have health problems from breathing secondhand smoke. (See our documents, Secondhand Smoke and Women and Smoking.)

Effects of smoking on how long you live and your quality of life

Based on data collected from 1995 to 1999, the CDC estimated that adult male smokers lost an average of 13.2 years of life and female smokers lost 14.5 years of life because of smoking.
But not all of the health problems related to smoking result in deaths. Smoking affects a smoker's health in many ways, harming nearly every organ of the body and causing diseases. According to the CDC, in 2000 about 8.6 million people had at least one chronic disease because they smoked or had smoked. Many of these people were suffering from more than one smoking-related problem. The diseases seen most often were chronic bronchitis, emphysema, heart attacks, strokes, and cancer. And some studies have found that male smokers may be more likely to be sexually impotent (have erectile dysfunction) than non-smokers. These problems can steal away a person's quality of life long before death. Smoking-related illness can limit a person's daily life by making it harder to breathe, get around, work, or play.

Cancer causes: Theories throughout history

From the earliest times, physicians have puzzled over the causes of cancer. Ancient Egyptians blamed cancers on the gods.

Humoral theory

Hippocrates believed that the body had 4 humors (body fluids) :blood, phlegm, yellow bile, and black bile. When the humors were balanced, a person was healthy. Too much or too little of any of the humors caused disease. An excess of black bile in various body sites was thought to cause cancer. This theory of cancer was passed on by the Romans and was embraced by the influential doctor Galen’s medical teaching, which remained the unchallenged standard through the Middle Ages for over 1,300 years. During this period, the study of the body, including autopsies, was prohibited for religious reasons, which limited progress of medical knowledge.

Lymph theory

Among theories that replaced the humoral theory of cancer, was the formation of cancer by another body fluid, lymph. Life was believed to consist of continuous and appropriate movement of the fluid parts of the body through the solid parts. Of all the fluids, the most important were blood and lymph. Stahl and Hoffman theorized that cancer was composed of fermenting and degenerating lymph varying in density, acidity, and alkalinity. The lymph theory gained rapid support. The eminent Scottish surgeon John Hunter (1728−1793) agreed that tumors grow from lymph constantly thrown out by the blood.

Blastema theory

In 1838, German pathologist Johannes Muller demonstrated that cancer is made up of cells and not lymph, but he believed that cancer cells did not come from normal cells. Muller proposed that cancer cells developed from budding elements (blastema) between normal tissues. His student, Rudolph Virchow (1821−1902), the famous German pathologist, determined that all cells, including cancer cells, are derived from other cells.

Chronic irritation theory

Virchow proposed that chronic irritation was the cause of cancer, but he falsely believed that cancers “spread like a liquid.” In the 1860s, German surgeon, Karl Thiersch, showed that cancers metastasize through the spread of malignant cells and not through some unidentified fluid.

Trauma theory

Despite advances in the understanding of cancer, from the late 1800s until the 1920s, trauma was thought by some to cause cancer. This belief was maintained despite the failure of injury to cause cancer in experimental animals.

Infectious disease theory

Zacutus Lusitani (1575−1642) and Nicholas Tulp (1593−1674), 2 doctors in Holland, concluded at almost the same time that cancer was contagious. They made this conclusion based on their experiences with breast cancer in members of the same household. Lusitani and Tulp publicized the contagion theory in 1649 and 1652, respectively. They proposed that cancer patients should be isolated, preferably outside of cities and towns, in order to prevent the spread of cancer.
Throughout the 17th and 18th centuries, some believed that cancer was contagious. In fact, the first cancer hospital in France was forced to move from the city in 1779 because people feared cancer would spread throughout the city. Although human cancer, itself, is not contagious, we now know that certain viruses, bacteria, and parasites can increase a person’s risk of developing cancer.

Report: Breast Cancer Death Rates Decline, but More Slowly Among Poor

A new report from the American Cancer Society finds that deaths from breast cancer in the United States continue to decline steadily. However, the decline has been faster for women who live in more affluent areas. Women from poor areas now have the highest rates of death from breast cancer.

“In general, progress in reducing breast cancer death rates is being seen across races/ethnicities, socioeconomic status, and across the U.S.,” said Otis W. Brawley, M.D., chief medical officer of the American Cancer Society. “However, not all women have benefitted equally. Poor women are now at greater risk for breast cancer death because of less access to screening and better treatments. This continued disparity is impeding real progress against breast cancer, and will require renewed efforts to ensure that all women have access to high-quality prevention, detection, and treatment services.”
The findings are published in Breast Cancer Facts & Figures 2011-2012 and in Breast Cancer Statistics, 2011 in CA: A Cancer Journal for Clinicians. The report, published every two years since 1996, provides detailed analyses of breast cancer trends and presents information on known risk factors for the disease, factors that influence survival, the latest data on prevention, early detection, treatment, and ongoing research.

Steady Decline

Breast cancer death rates have declined steadily since 1990. The drop has been larger among women under 50 (3.2% per year) than among women over 50 (2.0% per year).
An estimated 230,480 women will be diagnosed with invasive breast cancer in 2011. Breast cancer is the most common cancer among women in the United States, after skin cancer. Breast cancer accounts for nearly 1 in 3 cancers diagnosed in women. Men can get breast cancer too, but it is much rarer and accounts for only 1% of breast cancer cases in the United States. An estimated 39,520 women are expected to die from the disease in 2011.
In January 2008, the latest year for which statistics are available, approximately 2.6 million women living in the U.S. had a history of breast cancer. More than half of them were diagnosed less than 10 years earlier. Most of them were cancer-free, while others still had evidence of cancer and may have been undergoing treatment.

Race and Socioeconomic Factors

White women get breast cancer at a higher rate than African-American women, but African-American women are more likely to get breast cancer before they are 40, and are more likely to die from it at any age. This is likely because the cancer is more advanced when it is found in African American women, and because survival at every cancer stage is worse among African American women. Incidence and death rates for breast cancer are lower among women of other racial and ethnic groups.
Poverty and a lack of health insurance are also associated with lower breast cancer survival. In 2008, 51.4% of poor women ages 40 and older had a screening mammogram in the past 2 years compared to 72.8% of women who were not poor. The presence of additional illnesses, unequal access to medical care, and disparities in treatment also likely contributed to differences in breast cancer survival.
Death rates were highest among women who lived in affluent areas until the early 1990s, but since that time rates have been higher among women in poorer areas because the decline in their death rates began later and was slower.

Differences Among States

Trends in breast cancer death rates also vary by state. During 1998-2007, death rates declined in 36 states and the District of Columbia, but remained relatively unchanged in the remaining 14 states (Alabama, Alaska, Arkansas, Hawaii, Louisiana, Mississippi, Missouri, Montana, New Mexico, Oklahoma, South Dakota, Utah, Vermont, and Wyoming). The lack of a decline in these states is likely related to differences in the availability and quality of mammogram screening, as well as state differences in racial and socioeconomic composition.

Risk Factors

Breast cancer incidence and death rates generally increase with age. Ninety-five percent of new cases and 97% of breast cancer deaths occurred in women 40 years old and older.
Obese breast cancer patients have about a 30% higher risk of death compared to those who maintain a healthy weight. Research also suggests that exercise during and after treatment improves outcomes.
Women with a family history of breast cancer, especially in a mother, sister, daughter, father or brother, are at increased risk of developing breast cancer.
To find breast cancer early, when treatments are more likely to be successful, the American Cancer Society recommends women 40 and older have a mammogram and clinical breast exam every year, and younger women have clinical breast exams periodically as well.

By Stacy Simon

Health Insurers Making More Money Than Ever While People Postpone Medical Care

If people continue paying their premiums but use medical services less, health insurers make more money because they have to pay out less. It is an irony that as people struggle and postpone medical care, the insurance companies thrive. It is one of the paradoxes of a recessionary environment

Both UnitedHealth Group and Cigna have noticed a drop in hospital stays and medical use.

So far, the irony is understandable. It is like a year with no natural disasters, insurance companies make more money. However, if they are doing so well why are they asking for higher premiums if they are cash rich and paying off nice dividends to their shareholders?

Some in the health insurance industry say they want double-digit premium increases in case there is a sudden rush in demand when people have more money and start going back to the doctors and hospitals, etc. They also say that care is becoming more expensive.

However, it appears much of America has changed over the last few years. People have become much more conscious about the cost of things. This fundamental change may have an impact on how Americans view their health care options.

Household budgets are being squeezed from many directions. The price of gas has risen, food prices have rocketed, and utilities have gone up. The amount of money in the average American household today after paying off all running costs has gone down. People are much more price conscious today, and doctors and other health care providers have noticed it.

With the high price of gas now, the cost of getting somewhere might impact on a person's decision on whether to drive a long way to see a specialist.

Diagnostic tests are not what they were. The number of patients asking for an MRI or CT scan, for example, when they come in with something that is not life-threatening has dropped dramatically.

Many people are finding that, even with health insurance, they cannot afford to pay for medical or dental work - a growing number of individuals are simply putting things off.

Experts seem to have no idea when (or if) this recessionary mindset will go away.

The chances of a good rebound in the medical market have been undermined somewhat by the increase in how much individuals have to pay for their medical care. Many companies have reduced benefits considerably, they have raised co-payments and deductibles - the patient has to pay much more than he/she used to.

In 2008, 5% of employees who were covered by their employers had a deductible of 2,000, compared to 10% today.

If you are liable for the first two thousand dollars, that is a lot of money to think about.

While in the past many people would opt for brand-name medications, today they want the generic version because they are much cheaper.

Health insurers seem to be sure things will pick up later on this year. And it is this projected rebound that concerns them. That is why they say they need double-digit premium increases - some are asking for 22% rises.

Perhaps insurers are trying to beat 2014, when the health care law comes into full force.

Leukemia facts

  • Leukemia is a cancer of the blood cells.
  • While the exact cause(s) of leukemia is not known, risk factors have been identified.
  • Leukemias are grouped by how quickly the disease develops (acute or chronic) as well as by the type of blood cell that is affected (lymphocytes or myelocytes). The four main types of leukemia include acute lymphocytic leukemia (ALL), chronic lymphocytic leukemia (CLL), acute myelocytic leukemia (AML), and chronic myelocytic leukemia (CML).
  • People with leukemia are at significantly increased risk for developing infections, anemia, and bleeding. Other symptoms and signs include easy bruising, weight loss, night sweats, and unexplained fevers.
  • The diagnosis of leukemia is supported by findings of the medical history and examination, and examining blood and bone marrow samples under a microscope.
  • Treatment of leukemia depends on the type of leukemia, certain features of the leukemia cells, the extent of the disease, and prior history of treatment, as well as the age and health of the patient.
  • Most patients with leukemia are treated with chemotherapy. Some patients also may have radiation therapy and/or bone marrow transplantation.
  • There is no known way to prevent leukemia.
  • The prognosis of leukemia depends upon several factors, including the patient's age, the type of leukemia, and the extent to which the cancer has spread.

What is the treatment for cancer?

The treatment for cancer is usually designed by a team of doctors or by the patient's oncologist and is based on the type of cancer and the stage of the cancer. Most treatments are designed specifically for each individual. In some people, diagnosis and treatment may occur at the same time if the cancer is entirely surgically removed when the surgeon removes the tissue for biopsy.
Although patients may obtain a unique treatment protocol for their cancer, most treatments have one or more of the following components: surgery, chemotherapy, radiation therapy, or combination treatments (a combination of two or all three treatments).
Individuals obtain variations of these treatments for cancer. Patients with cancers that cannot be cured (completely removed) by surgery usually will get combination therapy, the composition determined by the cancer type and stage.
Palliative therapy (medical care or treatment used to reduce disease symptoms but unable to cure the patient) utilizes the same treatments described above. It is done with the intent to extend and improve the quality of life of the terminally ill cancer patient. There are many other palliative treatments to reduce symptoms such as pain medications and antinausea medications.

What is the prognosis for cancer?

The prognosis (outcome) for cancer patients may range from excellent to poor. The prognosis is directly related to both the type and stage of the cancer. For example, many skin cancers can be completely cured by removing the skin cancer tissue; similarly, even a patient with a large tumor may be cured after surgery and other treatments like chemotherapy (note that a cure is often defined by many clinicians as a five-year period with no reoccurrence of the cancer). However, as the cancer type either is or becomes aggressive, with spread to lymph nodes or is metastatic to other organs, the prognosis decreases. For example, cancers that have higher numbers in their staging (for example, stage III or T3N2M1; see staging section above) have a worse prognosis than those with low (or 0) numbers. As the staging numbers increase, the prognosis worsens.
There are many complications that may occur with cancer; many are specific to the cancer type and stage and are too numerous to list here. However, some general complications that may occur with both cancer and its treatment protocols are listed below:
  • Fatigue (both cancer and treatments)
  • Anemia (both)
  • Loss of appetite (both)
  • Insomnia (both)
  • Hair loss (treatments mainly)
  • Nausea (both)
  • Lymphedema (both)
  • Pain (both)
  • Immune system depression (both)