By ROBERT PEAR
Published: September 9, 2010
WASHINGTON — A new government study says President Obama’s health care law will have negligible effects on total national health spending in the next 10 years, neither slowing nor fueling the explosive growth of medical costs.
Related
Times Topic: Health Care Reform
About 32.5 million people will gain coverage, and health spending will grow slightly faster than projected under prior law — at an annual rate of 6.3 percent, rather than 6.1 percent, the report said.
The government report, by the office of the chief Medicare actuary, undermines the claims of the law’s fiercest critics and some of its biggest champions.
Cuts in Medicare spending, which start in the next few months, and a tax on high-cost employer-sponsored health plans, which takes effect in 2018, will largely offset the cost of expanding Medicaid and subsidizing private insurance for low-income people, said the report, being published online Thursday by the journal Health Affairs.
“In the aggregate,” said Andrea M. Sisko, the principal author of the report, “it appears that the new law will have a moderate effect on health spending growth rates and the health care share of the economy.”
In 2009, the report said, national health spending, public and private, totaled $2.5 trillion and accounted for 17.3 percent of the economy, as measured by the gross domestic product. The report predicts that health spending will rise to $4.6 trillion and account for 19.6 percent of the economy in 2019.
By contrast, in February, before passage of the comprehensive health care law, the same team of government experts, using the same economic and demographic assumptions, predicted that national health spending would reach $4.5 trillion, or 19.3 percent of the gross domestic product, in 2019.
The report foresees a big jump in health spending in 2014, when major provisions of the new law, including a requirement for most Americans to have insurance, take effect.
From 2013 to 2014, the report says, overall health spending is expected to increase by 9.2 percent, which is significantly more than the 6.6 percent increase predicted in February.
The report foresees an abrupt increase in private health insurance spending, expected to rise 12.8 percent in 2014, to $1.1 trillion. The government had been predicting a 6.7 percent increase before the signing of the new law.
“We expect that the level of health care spending for the formerly uninsured will nearly double as a result of their gaining coverage” through new insurance exchanges, the report said. “For those who previously held individually purchased coverage, many are projected to be eligible for federal premium subsidies.”
The report predicts that some workers will have to pay more out of pocket as many employers scale back coverage in 2018 to avoid the tax on high-cost plans.
Under the law, all states will have insurance exchanges where individuals, families and small businesses can buy coverage. The report predicts that 30.6 million people will be getting insurance through such exchanges by 2019, significantly more than the 24 million estimated by the Congressional Budget Office.
The report offers the first official estimates of new administrative costs. Federal and state agencies will spend more than $37 billion over 10 years creating and operating the exchanges, it said, and “Medicaid administration costs at the state and federal level are projected to increase by $31 billion over the same period.”
Friday, September 10, 2010
Topical Gel Catches Up With Pills for Relief
By LAURIE TARKAN
Published: September 6, 2010
When I strained a back muscle playing tennis not long ago, my doubles partner, who happened to be a doctor, pulled a tube of cream from her gym bag and told me to rub it on.
Related
Health Guides: Pain Medications | Osteoarthritis
It wasn’t Bengay or one of those instant ice gels. It was a nonsteroidal anti-inflammatory drug, like Advil or Motrin, in a cream applied to the skin. She raved about the stuff, which she buys over the counter when she goes to Europe, and lamented that it is so hard to find in the United States.
In fact, Europeans have long been able to buy nonsteroidal anti-inflammatory drugs, or Nsaids (pronounced EN-seds), in gels, creams, sprays and patches to ease muscle and joint pain more directly than a pill. But in the United States, the first of these topical Nsaids was approved just three years ago, for prescription use only, with a “black box” insert warning of side effects.
“I slap it on as soon as I get an injury,” said R. Andrew Moore, a pain researcher at the University of Oxford in England who was an author of a recent analysis of studies on the use of topical Nsaids for acute injuries like sprains and strains. (Dr. Moore has received research financing from and has consulted for drug companies in the past.)
At first, he said, the researchers were skeptical of the drugs. Older studies had been poorly designed or too brief, and there has been little evidence of effectiveness for other types of medicated creams or those containing the chili pepper component capsaicin.
But a number of new controlled trials and meta-analyses like Dr. Moore’s suggest that topical Nsaids are as effective as their oral counterparts for treating osteoarthritis in the knee and hand as well as musculoskeletal injuries like soreness and tendinitis.
The main advantage of a skin cream is that it bypasses the stomach and much of the bloodstream, theoretically minimizing serious side effects. Oral Nsaids can be toxic to the kidneys, and they increase the risk of gastrointestinal bleeding. And some, including Vioxx and Bextra, were taken off the market after they were linked to heart attacks and strokes.
“The turning point for topical Nsaids was the fright over heart problems with Vioxx,” Dr. Moore said. “Suddenly there were tons of folks who thought topical Nsaids were a good idea.”
Dr. Roy D. Altman, a rheumatology professor at the David Geffen School of Medicine at the University of California, Los Angeles, said the drugs might be especially helpful for “the elderly or those taking multiple medications, who were not getting treated but who can now use topical Nsaids and get some benefit.”
(Dr. Altman has consulted with Novartis, which makes one of the painkillers, Voltaren gel.)
Another leading pain researcher, Dr. Roger Chou, an associate professor of medicine at Oregon Health and Science University, noted that the skin creams delivered “very high joint concentrations of the topical Nsaid, higher than with standard oral doses, with very low blood levels” — less than 5 percent of those found with oral Nsaids.
In clinical trials, the skin creams are linked to a higher rate of redness, irritation and rash. And the three topical Nsaids sold in this country — Voltaren gel, the Flector Patch and Pennsaid, a liquid — all contain the Nsaid diclofenac, whose oral version has been linked to liver damage.
The risks in the most vulnerable population — people with other illnesses, like liver disease, or those on blood thinners — are not known, because these patients are generally excluded from studies. One analysis of 19 studies of older adults found that about 15 percent of patients had gastrointestinal complaints, although not life-threatening ones.
“Future research needs to be done using patients with co-morbidities to know that these agents are safe in the highest-risk population,” said the author of the analysis, Dr. Una Makris, an associate research scientist at the Yale School of Medicine.
Still, in one of the only head-to-head trials between topical and oral Nsaids, subjects taking the pills had a much higher rate of indigestion, diarrhea, abdominal pain, abnormal liver tests and anemia than those using the creams.
No randomized, controlled study has assessed the risks for serious events like heart attacks, kidney failure and gastrointestinal bleeding, but other types of studies have found no association between topical Nsaids and these serious risk factors.
The American College of Rheumatology is rewriting its guidelines for osteoarthritis management and will include topical Nsaids in the recommendations, said Dr. Altman, who is on the guidelines committee.
Sports medicine and pain doctors are also recommending them for problems like tennis elbow, Achilles tendinitis and overuse injuries and strains. “We used them off label for a while before they were approved,” said Dr. Robin M. Gehrmann, the director of sports medicine at the University of Medicine and Dentistry of New Jersey. “Now that you can just write a prescription, I use them in my practice a lot more.”
Since the Food and Drug Administration approved the first topical Nsaid in 2007, sales in the United States have soared — to more than $264 million in 2009, according to IMS Health, a health care research company. The average copayment for a month’s supply of Voltaren gel or Pennsaid is around $30.
“I think many people are not aware of topical Nsaids, or there is a perception that they don’t work well, or people confuse topical Nsaids with other topical drugs, like the topical salicylates or capsaicin,” Dr. Chou said.
The topical painkillers are not for everyone. Aside from the possible risks to people with other illnesses, the drugs are not helpful for patients with pain throughout the body, like fibromyalgia, and should not be used along with oral Nsaids.
Nor are they recommended for stress fractures or tendon tears, because anti-inflammatory drugs in general have been shown to slow healing of tendons and bones.
And young, healthy patients may not want to bother with creams or gels, which have their maximum effect if applied four times a day. “It’s easier to pop a pill,” Dr. Altman said.
But for immediate relief of my tennis-related muscle pull, the cream was handy and helpful.
Published: September 6, 2010
When I strained a back muscle playing tennis not long ago, my doubles partner, who happened to be a doctor, pulled a tube of cream from her gym bag and told me to rub it on.
Related
Health Guides: Pain Medications | Osteoarthritis
It wasn’t Bengay or one of those instant ice gels. It was a nonsteroidal anti-inflammatory drug, like Advil or Motrin, in a cream applied to the skin. She raved about the stuff, which she buys over the counter when she goes to Europe, and lamented that it is so hard to find in the United States.
In fact, Europeans have long been able to buy nonsteroidal anti-inflammatory drugs, or Nsaids (pronounced EN-seds), in gels, creams, sprays and patches to ease muscle and joint pain more directly than a pill. But in the United States, the first of these topical Nsaids was approved just three years ago, for prescription use only, with a “black box” insert warning of side effects.
“I slap it on as soon as I get an injury,” said R. Andrew Moore, a pain researcher at the University of Oxford in England who was an author of a recent analysis of studies on the use of topical Nsaids for acute injuries like sprains and strains. (Dr. Moore has received research financing from and has consulted for drug companies in the past.)
At first, he said, the researchers were skeptical of the drugs. Older studies had been poorly designed or too brief, and there has been little evidence of effectiveness for other types of medicated creams or those containing the chili pepper component capsaicin.
But a number of new controlled trials and meta-analyses like Dr. Moore’s suggest that topical Nsaids are as effective as their oral counterparts for treating osteoarthritis in the knee and hand as well as musculoskeletal injuries like soreness and tendinitis.
The main advantage of a skin cream is that it bypasses the stomach and much of the bloodstream, theoretically minimizing serious side effects. Oral Nsaids can be toxic to the kidneys, and they increase the risk of gastrointestinal bleeding. And some, including Vioxx and Bextra, were taken off the market after they were linked to heart attacks and strokes.
“The turning point for topical Nsaids was the fright over heart problems with Vioxx,” Dr. Moore said. “Suddenly there were tons of folks who thought topical Nsaids were a good idea.”
Dr. Roy D. Altman, a rheumatology professor at the David Geffen School of Medicine at the University of California, Los Angeles, said the drugs might be especially helpful for “the elderly or those taking multiple medications, who were not getting treated but who can now use topical Nsaids and get some benefit.”
(Dr. Altman has consulted with Novartis, which makes one of the painkillers, Voltaren gel.)
Another leading pain researcher, Dr. Roger Chou, an associate professor of medicine at Oregon Health and Science University, noted that the skin creams delivered “very high joint concentrations of the topical Nsaid, higher than with standard oral doses, with very low blood levels” — less than 5 percent of those found with oral Nsaids.
In clinical trials, the skin creams are linked to a higher rate of redness, irritation and rash. And the three topical Nsaids sold in this country — Voltaren gel, the Flector Patch and Pennsaid, a liquid — all contain the Nsaid diclofenac, whose oral version has been linked to liver damage.
The risks in the most vulnerable population — people with other illnesses, like liver disease, or those on blood thinners — are not known, because these patients are generally excluded from studies. One analysis of 19 studies of older adults found that about 15 percent of patients had gastrointestinal complaints, although not life-threatening ones.
“Future research needs to be done using patients with co-morbidities to know that these agents are safe in the highest-risk population,” said the author of the analysis, Dr. Una Makris, an associate research scientist at the Yale School of Medicine.
Still, in one of the only head-to-head trials between topical and oral Nsaids, subjects taking the pills had a much higher rate of indigestion, diarrhea, abdominal pain, abnormal liver tests and anemia than those using the creams.
No randomized, controlled study has assessed the risks for serious events like heart attacks, kidney failure and gastrointestinal bleeding, but other types of studies have found no association between topical Nsaids and these serious risk factors.
The American College of Rheumatology is rewriting its guidelines for osteoarthritis management and will include topical Nsaids in the recommendations, said Dr. Altman, who is on the guidelines committee.
Sports medicine and pain doctors are also recommending them for problems like tennis elbow, Achilles tendinitis and overuse injuries and strains. “We used them off label for a while before they were approved,” said Dr. Robin M. Gehrmann, the director of sports medicine at the University of Medicine and Dentistry of New Jersey. “Now that you can just write a prescription, I use them in my practice a lot more.”
Since the Food and Drug Administration approved the first topical Nsaid in 2007, sales in the United States have soared — to more than $264 million in 2009, according to IMS Health, a health care research company. The average copayment for a month’s supply of Voltaren gel or Pennsaid is around $30.
“I think many people are not aware of topical Nsaids, or there is a perception that they don’t work well, or people confuse topical Nsaids with other topical drugs, like the topical salicylates or capsaicin,” Dr. Chou said.
The topical painkillers are not for everyone. Aside from the possible risks to people with other illnesses, the drugs are not helpful for patients with pain throughout the body, like fibromyalgia, and should not be used along with oral Nsaids.
Nor are they recommended for stress fractures or tendon tears, because anti-inflammatory drugs in general have been shown to slow healing of tendons and bones.
And young, healthy patients may not want to bother with creams or gels, which have their maximum effect if applied four times a day. “It’s easier to pop a pill,” Dr. Altman said.
But for immediate relief of my tennis-related muscle pull, the cream was handy and helpful.
Stress Hormone Predicts Heart Death
High Cortisol Levels Raise Risk of Heart Disease, Stroke 5-Fold
By Salynn Boyles
WebMD Health News
Reviewed by Laura J. Martin, MD Sept. 9, 2010 -- Doctors have long warned patients that stress is bad for the heart. Now new research provides direct evidence to back up the warning.
In the newly published study, high levels of the stress hormone cortisol in the urine were associated with a dramatic increase in death from cardiovascular disease years later.
Compared to study participants with the lowest cortisol levels, those with the highest levels were five times as likely to die of heart attack, stroke or other cardiovascular causes over six years of follow up.
The association was seen both in people with and without heart disease when they entered the study.
While earlier research suggested a link between high cortisol levels and cardiovascular risk, the study is the first to directly test the hypothesis that elevated stress hormones predict heart disease death, says lead researcher Nicole Vogelzangs, PhD, of VU University Medical Center in the Netherlands.
“We were actually surprised to find that the association was so strong,” Vogelzangs tells WebMD. “Cortisol levels in older adults were clearly predictive of death from cardiovascular causes, but were not predictive of other causes of death.”
The study was published less than a week after a separate team of researchers reported that high levels of the hormone in hair samples predict heart attack risk.
Cortisol Predicts Heart Health
Secreted by the adrenal glands, cortisol is known as the "stress hormone" because it is produced in high levels as the body’s "fight or flight" response to stressful events.
Prolonged cortisol production resulting from chronic stress is thought to play a role in a wide range of diseases, including diabetes, osteoporosis, and heart disease.
Cortisol can be measured in the blood, but blood measurements show only a snapshot of stress at the moment, which may be elevated in response to having blood drawn, Vogelzangs says.
In the new study, published in the Journal of Clinical Endocrinology & Metabolism, researchers measured cortisol levels over a 24-hour period in urine samples.
The study included 861 people aged 65 and older followed for an average of about six years after 24-hour cortisol levels were measured.
During this time, 183 study participants died. Death certificates were examined to determine the cause of death.
While urinary cortisol did not predict death from non-cardiovascular causes, it strongly predicted death from heart attack and stroke.
When divided into three groups based on levels of the stress hormone, the third of study participants with the highest cortisol levels had a fivefold increased risk of dying from cardiovascular causes as the third with the lowest levels.
Clinical Value of Stress Hormone Test Not Clear
In the study reported earlier this month, researchers from the University of Western Ontario measured cortisol levels in hair samples as a marker of chronic stress.
Study co-researcher Stan VanUum, MD, PhD, explains that hair grows at a rate of about 1 centimeter a month. So a 3 centimeter hair sample would measure stress levels over 3 months.
The researchers found that hair cortisol levels were a more important predictor of heart attack risk than established risk factors like high blood pressure and cholesterol.
VanUum and Vogelzangs agree that more research is needed to determine if stress hormone measurement can provide meaningful information about heart risk in clinical practice.
There is no consensus about what "high" and "normal" cortisol levels should be in terms of cardiovascular risk. And measuring levels of the hormone in hair remains expensive and labor intensive.
While there is some suggestion that cortisol levels might be reduced with exercise, weight loss or even the use of antidepressants, it is far from clear if directly targeting cortisol lowers cardiovascular risk.
“These studies reinforce the message that stress is bad for the heart, but we don’t really know if we can reduce stress hormone levels or what impact this would have,” VanUum tells WebMD
By Salynn Boyles
WebMD Health News
Reviewed by Laura J. Martin, MD Sept. 9, 2010 -- Doctors have long warned patients that stress is bad for the heart. Now new research provides direct evidence to back up the warning.
In the newly published study, high levels of the stress hormone cortisol in the urine were associated with a dramatic increase in death from cardiovascular disease years later.
Compared to study participants with the lowest cortisol levels, those with the highest levels were five times as likely to die of heart attack, stroke or other cardiovascular causes over six years of follow up.
The association was seen both in people with and without heart disease when they entered the study.
While earlier research suggested a link between high cortisol levels and cardiovascular risk, the study is the first to directly test the hypothesis that elevated stress hormones predict heart disease death, says lead researcher Nicole Vogelzangs, PhD, of VU University Medical Center in the Netherlands.
“We were actually surprised to find that the association was so strong,” Vogelzangs tells WebMD. “Cortisol levels in older adults were clearly predictive of death from cardiovascular causes, but were not predictive of other causes of death.”
The study was published less than a week after a separate team of researchers reported that high levels of the hormone in hair samples predict heart attack risk.
Cortisol Predicts Heart Health
Secreted by the adrenal glands, cortisol is known as the "stress hormone" because it is produced in high levels as the body’s "fight or flight" response to stressful events.
Prolonged cortisol production resulting from chronic stress is thought to play a role in a wide range of diseases, including diabetes, osteoporosis, and heart disease.
Cortisol can be measured in the blood, but blood measurements show only a snapshot of stress at the moment, which may be elevated in response to having blood drawn, Vogelzangs says.
In the new study, published in the Journal of Clinical Endocrinology & Metabolism, researchers measured cortisol levels over a 24-hour period in urine samples.
The study included 861 people aged 65 and older followed for an average of about six years after 24-hour cortisol levels were measured.
During this time, 183 study participants died. Death certificates were examined to determine the cause of death.
While urinary cortisol did not predict death from non-cardiovascular causes, it strongly predicted death from heart attack and stroke.
When divided into three groups based on levels of the stress hormone, the third of study participants with the highest cortisol levels had a fivefold increased risk of dying from cardiovascular causes as the third with the lowest levels.
Clinical Value of Stress Hormone Test Not Clear
In the study reported earlier this month, researchers from the University of Western Ontario measured cortisol levels in hair samples as a marker of chronic stress.
Study co-researcher Stan VanUum, MD, PhD, explains that hair grows at a rate of about 1 centimeter a month. So a 3 centimeter hair sample would measure stress levels over 3 months.
The researchers found that hair cortisol levels were a more important predictor of heart attack risk than established risk factors like high blood pressure and cholesterol.
VanUum and Vogelzangs agree that more research is needed to determine if stress hormone measurement can provide meaningful information about heart risk in clinical practice.
There is no consensus about what "high" and "normal" cortisol levels should be in terms of cardiovascular risk. And measuring levels of the hormone in hair remains expensive and labor intensive.
While there is some suggestion that cortisol levels might be reduced with exercise, weight loss or even the use of antidepressants, it is far from clear if directly targeting cortisol lowers cardiovascular risk.
“These studies reinforce the message that stress is bad for the heart, but we don’t really know if we can reduce stress hormone levels or what impact this would have,” VanUum tells WebMD
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