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From the state Department of Health and Human Services comes notice that on Wednesday, April 2, four more barbecue restaurants in Lexington, which promotes itself as the World Capital of Barbecue, are going smoke-free in observance of Kick Butts Day.

The four are John Wayne's Barbecue, Smokey Joe's Barbecue, the Barbeque House and Whitley's Restaurant. They join several other restaurants that went smoke-free earlier: Backcountry BBQ, The Barbecue Center, Lexington Barbecue and Henry James Family Dining.

To answer a question no one has asked yet, the restaurants will still be using hickory smoke to make their barbecue. So far as I know, any link between hickory smoke and cancer remains unproven. [insert rim shot here]

The New England Journal of Medicine has two pieces up stemming from a case now before the Supreme Court regarding the constitutionality of the District of Columbia's ban on handguns. The Bush Administration has urged the high court to rule the laws an unconstitutional violation of the Second Amendment.

One article, by a physician and public-health professional, looks at gun violence as a public health issue. It cites studies that undermine what it calls "myths" surrounding the benefits of widespread gun ownership.

The second piece, by a law professor, simply examines the constitutional issues (without touching on public health) in what strikes me as a logical and nuanced way. It concludes that the court might well strike the D.C. ban and would have a logical basis for doing so, albeit not one everyone would agree with.

The Journal also has published an editorial urging the justices to consider the public-health implications along with the constitutional questions.

Read these pieces and tell me what you think.

On Saturday, I published an article about a report from the nonprofit Families USA estimating that on average, about three working-age people died in North Carolina every day in 2006 because they lacked health insurance. I received a couple of e-mail responses.

One was from Sheryl Dawson, who said that as a health insurance agent, she sees many people turned down for health insurance because of pre-existing medical conditions:

As a licensed health insurance agent, I cannot tell you the number of people what are turned down by insurance companies, and cannot get coverage no matter HOW MUCH they pay. My estimate is that about half of the applications I submit are turned down because of health issues, including diabetes, sleep apnea, hypertension, pregnancy, high cholesterol/triglycerides, heart issues, depression, smoking, cancer and a wide variety of other problems. And don't you think it makes sense that these people -- already with a serious enough disease to warrant exclusion from being insured -- would die more frequently? The ONLY way that these people can be insured is with group health insurance, where the laws force insurance companies to insure everyone in a company, not just the ones whose medical profile they like. Once these individuals lose their job, essentially they're screwed.

Another correspondent sent a link to a Cybercast News Service column taking issue with the original research on which the Families USA report is based. The headline on the column is a little misleading -- it says critics say it's "not true that thousands died for lack of health insurance." What the critics it quotes do say is a little more nuanced -- that there's no way you can know for sure how many people, if any, might be dying for lack of health insurance. (The column also goes into why people might not be insured and whether estimates of the number of uninsured are correct, questions the Families USA report didn't attempt to address.)

Novant Health, which owns Forsyth Medical Center and other hospitals, is talking with Greensboro Cardiology Associates about a possible sale, the practice's administrator says. I am not an expert on business deals of this type (I'm not an expert on business deals in general), so I throw this to you: What questions should I be asking?

Because of events such as last year's Moses Cone/Blue Cross Blue Shield standoff over reimbursement rates and the news that the aggressively growing nonprofit hospital company Novant Health might be buying a local medical practice, questions arise about whether nonprofit hospitals really are nonprofit.

Paul Levy tackles the question at his Running a Hospital blog. He is president and CEO of Beth Israel Deaconess Medical Center in Boston. He links to a Wall Street Journal article (only a preview is freely available) as well as reader comments. Levy writes:

In reviewing this issue, it seems to me that there is not always a bright line between the business behavior of a non-profit and a for-profit company. Both need to operate in the black to carry out their purpose. Both need to determine how to compete in a marketplace to achieve that. The strategies employed to do that might look quite similar. Both need to attract qualified people in both supervisory and line positions. The salaries and benefits offered, therefore, might be somewhat similar. Both depend on the vigilance of a Board of Directors to monitor management's performance and behavior. So the structure and functions of the boards overlap in several ways (but not totally, given the pertinent legal requirements). And, as a final level of control, both have regulators to ensure that appropriate community standards are maintained and enforced.

But there is a fundamental difference. The non-profit does not have shareholders who benefit financially from its operations. Its fundamental constituency is the community it serves. For a small community hospital, it is literally the local community. For an academic medical center like BIDMC, it is the local community, but it is also a regional, national, and indeed international community that benefits from the research and educational programs of the hospital.

Is this a difference without a distinction? I think not. I know that our Board and I would be making very different decisions about patient care, research, and training expenditures if we operated under a for-profit rubric. While we always have to be prudent about which services we offer, many more areas that do not generate a profit or that result in perpetual losses would likely be cut or eliminated if we were not a non-profit. As a matter of strict business, many of these could be jettisoned and provided by others outside of our hospital. But we believe that we owe to our patients and to the nurses and doctors who we are training to offer these as part of our public service mission.

I've just stumbled across a blog that might possibly be of help to health-care professionals trying to address how much time their patients wait. It's called "Wait Time & Delayed Care." Not being a health-care professional myself, I have no idea whether it would be truly helpful or not, but I pass it along for whatever it might be worth. Maybe patients can find something useful there, as well.

... you should see China's.

What's driving the increase in medical costs -- an increase that, in terms of hospital spending, is roughly twice the rate of inflation? An increase in chronic (and largely preventable) diseases such as adult-onset diabetes? That's part of it. The aging Boomer population? That's part of it, although nowhere near as big a part as most people think, writes blogger and former financial journalist Maggie Mahar. One big driver is the demand for the new -- new tests, new procedures, and, especially, new -- and quite expensive -- equipment:

As Paul Ginsburg, President of the Center for Studying Health Systems Change, explained in the January/February issue of Health Affairs: “hospitals have been increasing capacity, not predominantly by adding new beds but by expanding specialized facilities (such as operating rooms and imaging facilities) needed to serve patients with the latest technology.”

Consider, for example, what may be the world's most expensive medical device: a particle accelerator with a total price tag well over $100 million. The machine, which employs protons to bombard cancerous tumors, can deliver higher and more precise doses of radiation, and we have evidence that it is effective in treating certain rare cancers.

But we don’t know whether it offers any benefits when it comes to treating common cancers."That's far from established, and there's a good deal of controversy about it," said J. Frank Wilson, a professor of radiation oncology at the Medical College of Wisconsin recently told the Milwaukee Journal Sentinel.

Nevertheless, roughly a dozen proton therapy centers have been proposed throughout the country ...

Please keep your characters from marching right up to the edge of the page. Many of us still don't have electronic medical records yet, those papers sometimes have to be photocopied and not all photocopiers (even the very good ones) can get every last square micron of the form into their pictures.

Thank you.

Today is the inaugural National Healthcare Decisions Day. The day is aimed at highlighting the need for you to plan in advance for decisions you may need to make about your own health care as you age or if you become ill or are injured. It's also aimed at highlighting the need for you to designate who can make those decisions for you if you become unable. For example, if you are brain-dead, do you want to be kept alive on a respirator?

A number of agencies can provide information on various aspects of these decisions, including North Carolina End of Life Care Advisory Council, the Carolinas Center for Hospice and End of Life Care, North Carolina Hospital Association, North Carolina Medical Society, North Carolina Bar Association, North Carolina Coalition on Donation and the North Carolina Division of Aging
and Adult Services.

For more information, visit the National Healthcare Decisions Day Web site.

The Centers for Disease Control and Prevention held a teleconference on Thursday to talk about the flu season just past and to announce an important change in flu-shot recommendations. (Transcript here; New York Times article here.)

The 2007-08 season was worse than the preceding three seasons, the article said. The main reason was that the most virulent strain of flu virus wasn't exactly one of the ones covered by the flu vaccine, although the kind covered by the vaccine covered a slight variant.

It's important for the vaccine to be a good match for the predominant strains of flu virus. But they're sometimes difficult to match up because manufacturing vaccines must begin months before they will be needed -- time during which a totally new strain or variant of virus can emerge.

Here's the change: Up 'til now, the CDC has recommended that children between the ages of 5 and 18 be vaccinated only if they had high-risk medical conditions or if they lived in households in which it would be possible for them to infect someone with a high-risk medical condition. For 2008-09 if possible, and by 2009-10 for sure, the CDC is calling for all children between 5 and 18 to be vaccinated -- that's 30 million additional people.

Flu-shot manufacturers manufactured roughly 140 million doses of flu vaccine this past season. The CDC expects the supply to be greater next fall, although it won't know how much greater for about another month.

Remember the stakes: About 200,000 people get the flu in the U.S. every year, the CDC says, and about 36,000 people die of it.

The nonprofit group LifeSharers says that the first crack at transplants for those who need them should go to people who are organ donors themselves.

What do you think?

The Health Beat Blog says it bluntly: Medical practitioners are often slow to adopt well-researched, proven mental health interventions -- because they're rarely profitable.

... you'd think that health care practitioners would make it a priority to provide effective mental health treatment. But a 2005 study from the National Institutes of Mental Health (NIMH) and Harvard found that only one-third of mental health therapies received by patients meet minimal standards for adequacy as established in national guidelines. That means that when we know what works -- and even draw up guidelines to define best practices -- relatively few providers follow the rules. Why is it so hard to translate knowledge into practice?

Three academics -- Robert Drake, M.D. and Jonathan Skinner, Ph.D from Dartmouth Medical School, along with Goldman -- wrote an issue brief for the conference that looked at his very question. Their conclusion? It's all about the money.

According to the authors, most effective mental health treatment regimes are not purely medication-based but also involve psychosocial intervention -- that is, a program of cognitive and behavioral measures such as patient education, psychotherapy, and peer support. ...

Given [cognitive behavioral therapy]'s focus on self-esteem, perspective, and encouragement, it might come off as somewhat touchy-feely to the outside observer -- but in fact it's proven to be quite effective. ...

Why can't psychosocial treatments seem to catch a break? "Unlike new medications, where the marketing of new practices is supported and encouraged by patents," notes Drake et al. in their issue brief, "psychosocial treatments are not patented and therefore lack the economic incentives to promote them widely. Because it is difficult to market, doctors are less exposed to best practice strategies and consumers are often unaware of other strategies for treatment."

Speaking about this issue in person during a panel at the conference, Drake didn't mince words, noting that "no one makes a profit off psychosocial interventions, so they are used less often." Moreover, a treatment like CBT is not quick and easy: it's sequential, collaborative, and personalized. In short, it's messy, labor intensive -- and thus hard to sell.

Is there a way these "best practices" can be applied more widely when market forces appear to be arrayed in opposition? Or is this a problem the market cannot fix? I'm not much of an economist, so anyone who has some insights, please speak up.

This is a tad late for Earth Day, but here's a short piece on why we really need to take care of the species we've got.

Maybe the cure isn't worse than the disease, but it sure ain't good:

Two years ago, scientists had high hopes for new pills that would help people quit smoking, lose weight and maybe kick other tough addictions like alcohol and cocaine.

The pills worked in a novel way, by blocking pleasure centers in the brain that provide the feel-good response from smoking or eating. Now it seems the drugs may block pleasure too well, possibly raising the risk of depression and suicide.

Some pills that work in this way, the article points out, may not overact. But the pills may put some people at special risk, it says, given that a lot of people are both addicted to something and depressed.

A side-effect-free super anti-addiction pill would be a godsend, saving us no end of costs in public health (including wrecks), lost jobs and homes and destroyed relationships. But we aren't there, we can't see there from here and we have barely the beginnings of a map, it looks like.

The New England Journal of Medicine has posted an article online about the travails of the Food and Drug Administration. The agency has been criticized for its role in the withdrawal of Vioxx from the marketplace and recent problems with contaminated Heparin from China.

But we ask the FDA to do a lot with not very much:

The fundamental problem is that legislators have heaped more and more responsibility on the FDA without appropriately increasing its budget. Between 1988 and 2007, additional FDA responsibilities were imposed by 137 specific statutes, 18 statutes of general applicability, and 14 executive orders. At the same time, the FDA received a 2007 federal appropriation of only $1.57 billion -- less than 75% of the budget for the school district in its home county in Maryland, and about the same as the projected cost of the infamous Alaskan "bridge to nowhere." The number of federally appropriated personnel authorized for the FDA has decreased from 9167 in 1994 to 7856 in 2007. And the remaining personnel must work with inadequate information technology: 80% of the FDA's computer servers are more than 5 years old; critical clinical trial records are stored on paper in warehouses, largely inaccessible for analysis; and the information technology budget is about 40% of that for the Centers for Disease Control and Prevention.

More money may not be the answer; the answer may be redefining and limiting the FDA's role. I don't know. But it is clear that to do its job as currently defined, the FDA lacks adequate resources. In particular, it doesn't have enough staff to inspect the foreign facilities from which 80% -- yes, you read that right -- of our drugs and drug ingredients now come. Under the current circumstances, additional problems similar to that of the Heparin from China might be not just likely but inevitable.

UPDATE: Americans' confidence in the FDA "has hit rock bottom."

The Minnesota-based UnitedHealthcare Children's Foundation, a charitable nonprofit, is making grants of up to $5,000 for children who need critical health treatment and are not covered or not fully covered by their parents' health-insurance plans.

Parents and legal guardians can get more information or apply online at www.uhccf.org. The children must be 16 or younger. Families must meet certain economic guidelines, live in the U.S. and be covered by a commercial health benefit plan.

It's not online, but I had an article in Wednesday's paper about a talk given Tuesday night by Dr. Ed Weisbart at a forum sponsored by the League of Women Voters and the Moses Cone-Wesley Long Community Health Foundation.

Dr. Weisbart talked about the need to use more generic drugs, instead of brand-name prescriptions, primarily because doing so would save between $20 billion and $40 billion a year. He also said generics are safer because any safety issue with a drug tends to surface while it is still in the brand-name phase, before its generic equivalent can come on the market.

The article prompted an e-mail from Dr. John Lusk, a retired local physician active in the Greater Greensboro Society of Medicine. He writes:

A caveat for patients seeking less costly drugs is that they should realize that generics and brand name drugs are not all equal.

One should be certain that the generic being offered has been made by a reputable manufacturer. The major chains and the locally owned pharmacies most probably vet the source of their non-brand named drugs.

Your readers should be careful if drugs are ordered via the internet. This is especially true if the order is place with an off-shore supplier. Some of these medications have the potential to be counterfeit, and contain none of the active ingredient.

As you are more than likely aware, the FDA requires that tablets and capsules carry some type of identification, printed or embossed. I've seen some "ineffective" pills without these markings.

Another potential difference is the use of different excipients and binders. Occasionally one of these compounds will react with the active ingredient to render it inactive. I have sometimes seen evidence that pills pass thru an intestinal tract intact and almost unchanged in appearance.

I suppose the old advice is the best advice: Talk to your doctor and your pharmacist.

Via Health Beat, here's a compendium of articles in The American Prospect discussing health-care reform. (Intro here; follow "related articles" links to the right for the others.)

One key takeaway: The problem of the uninsured, big as it is, isn't the biggest problem with our health-care system. The biggest problem is cost, and until costs are contained, the problem of the uninsured may well not be addressed. Health Beat blogger Maggie Mahar quotes Dr. Marcia Angell, former editor-in-chief of The New England Journal of Medicine: "Costs are the central problem; universal health care would be easy if money were no object."

Almost as big as the issue of cost is the issue of what's politically possible: Out of all of the many ways in which health-care costs could be cut, what way, or combination of ways, can make it through the House and the Senate, particularly the latter, where not just 51 but 60 votes are needed (to prevent a filibuster)?

2009-10 may not be 1994 all over again, but the obstacles to any meaningful effort to control costs (and make other changes, such as expanding coverage) are many. Backers of significant change, of whatever type, shouldn't be confident that that change, or any change, will happen.

"Strap yourself in; this isn't pretty."

So warns Brian Klepper by way of introducing a new report from the Economics Policy Institute called "A Decade of Decline: The Erosion of Employer-Provided Health Care in the United States and California, 1995-2006."

Among Klepper's observations from the report:

• The drop in the percentage of American workers with employer-sponsored health insurance between 2000 and 2006 was bigger than the gain between 1995 and 2000, even though both stretches encompassed times of relative economic prosperity.
• The drop may be fueled by growth in health care costs that, between 2000 and 2006, were four times the increase in workers' earnings and five times the general rate of inflation.
• The drop is hitting all workers: "The burden of these employer cuts is not carried by part-time or marginal workers. Rather, the most dramatic loss is among workers with the strongest connection to the labor force."
• The actual number of American uninsured is probably substantially larger than the commonly cited 48 million.
• The drop has economic implications because of the relationship between health, productivity and competitiveness.
• Even those with insurance have higher costs and lower benefits than in the recent past.

"The market can make care and coverage less expensive and more available," Klepper writes. "But getting to a system that assures appropriate care to everyone within our borders must be facilitated through policy. It will require political will, backed by a national understanding, already firmly in place within our largest corporations, that without secure access to health care, our people cannot be highly productive or continue to lead on the global stage" (emphasis added)

I don't often say, "Go read the whole thing," but: Go read the whole thing.

The Henry J. Kaiser Family Foundation, which does research and communications related to health care, has a new poll up that, unsurprisingly, ranks health-care costs among Americans' top economic concerns.

Currently, the economy is Americans' No. 1 concern, but that issue takes in such disparate factors as gas prices, the jobless rate and stagnant/falling wages as well as health care.

You can read more here.