The Ponzi Scheme: U.S. Health Insurance

Medscape.com, March 17, 2009, by Nancy R. Terry — “Healthcare reform cannot wait, it must not wait, and it will not wait another year.” With those words, President Barack Obama, in his first address to a joint session of Congress, rallied Congress and the American people to tackle the “crushing cost of healthcare.” Yet, it remains to be seen whether the President’s reform efforts will target one of the most wasteful sectors of healthcare — the health insurance industry.

Recent postings on Medscape’s Physician Connect (MPC), an all-physician discussion board, deride the excesses of health insurance companies and exhort the need to restructure, if not eliminate, the for-profit health insurance industry.

“Commercial, for-profit health insurance is one of the greatest Ponzi schemes ever foisted on the public,” says a family medicine physician. “The executives are the ones that benefit to the detriment of everyone else. How else does the president of one of the largest insurance companies get to be a billionaire? By being at the top of the pyramid of companies’ and individuals’ premium payments.”

“The single most important factor in the atrociously high cost of healthcare in the United States is the rapacious, money-hungry insurance companies and their fat cat CEOs,” comments an MPC contributor.

“The damage that the insurance companies do is not limited to the salaries of the CEOs,” says another contributor. “They waste the time and resources of healthcare workers, institutions, and patients. They are clearly a negative, wasteful element in healthcare today that needs to be heavily regulated, changed, or eliminated.”

Physicians point to a number of supposedly routine practices of the health insurance companies that cry out for oversight. One MPC participant remarks that health insurance companies increase their premiums even as they decrease coverage. Another discussant notes that insurers typically burden physicians and patients with filing requirements as part of a strategy to delay or deny legitimate claims. According to one contributor, some companies frequently change their coding schemas to avoid paying legitimate claims. “The insurance companies make billions of dollars in profit each year,” says one MPC commentator, “and they do it by limiting care, denying claims, limiting contracts, and limiting reimbursements.”

The practice of systematically denying legitimate reimbursement claims by insurance companies has been the focus of an ongoing investigation by New York Attorney General Andrew Cuomo. In January 2009, Cuomo reached an agreement with UnitedHealth Group, Inc. that the insurer would shut down its controversial Ingenix database and pay $50 million to fund a nonprofit, independent database for the purpose of establishing fair compensation rates. The Ingenix database, which was owned by UnitedHealth, served all the major insurers and, according to The Wall Street Journal, skewed downward the “usual and customary” rates of out-of-network insurance reimbursements through “faulty data collection, poor pooling procedures, and lack of audits, thus forcing customers to pay more out of their own pockets for healthcare.” In February, WellPoint, Inc., the nation’s largest health insurer, agreed to Cuomo’s request to pay $10 million to help fund the new database. WellPoint is the sixth insurance company to make such an agreement with Cuomo’s office. As quoted by New York Daily News, Cuomo commented on the insurers’ use of the Ingenix database, saying, “This is as egregious a situation as I’ve seen, of a virtual monopoly.”

Is health insurance a scam? The 100 MPC postings in response to that question are unanimous in their assertion that the health insurance industry needs reform. Yet, MPC contributors are divided as to the extent and nature of that reform.

“The health insurance system is so profoundly flawed,” says one MPC contributor, “that the only solution is a nonprofit, single-payer healthcare system.” Other MPC contributors contend that a single-payer system would harbor its own set of problems. Comments a psychiatrist, “I would rather have evil insurance companies than absolute power concentrated in a single agency. If you have a complaint about an insurance company, you can complain to the regulators and drop the insurance. If you have a complaint about the government, you are screwed.”

Advocates of a single-payer system singled out Physicians for a National Health Program as a resource outlining the salient features of a single-payer system. Similarly, several advocates for reorganization of the for-profit insurance system directed readers to Real Health Reform, which proposes, among other healthcare reforms, the restructuring of private health insurance into a regulated utility.

Other contributors less concerned about the overall structure of the industry advocate that health insurance coverage should more closely resemble other types of insurance. “When we protect our house and car, the purpose has traditionally been to provide a safety net if the unforeseen happens to us,” points out an endocrinologist. “Health insurance is not that way. We have come to expect medical insurance to subsidize ordinary expenses, like our prescriptions and our office visits and any number of interventions that are not in themselves financially devastating, the way an auto collision or a home fire would be.” A family medicine physician comments, “Health insurance needs to be made into real insurance that only covers catastrophic events. Then it will be cheaper for everyone.”

Evident throughout the postings is a sense of frustration. One participant comments, “The people are not happy with health insurance, the physicians and allied personnel are not happy with health insurance. What is the government waiting for?”

Some MPC contributors refuse to take a wait-and-see attitude. They advocate that physicians who are disgruntled with the health insurance industry should effectively boycott health insurance.

“We need to immediately stop taking all third-party payments,” says an MPC contributor.

“Bill patients at the time of service,” advises another contributor. “Provide them with the invoice and tell them the truth, the larger truth — that you, the doctor, are not in the business of bandying about with insurance clerks and petty tyrants whose motivation is nothing but to frustrate payment and cost you valuable time and energy, which is duly relegated to patient care.”

“Stop making contracts with HMOs, hospitals, and health insurance,” recommends a neurologist. “Return to cash payment. When other doctors see it works for them the way it has for many, guess what? The yoyos who keep your insurance clerk and billing staff on hold for 2 hours asking for notes and records will be collecting pink slips.”

But the question remains: will the President’s health reform initiative take on the health insurance industry? MPC contributors hope the answer to that question is yes. “Our healthcare system is broken largely due to the insurance companies,” comments an MPC contributor. A urologist agrees, “Only through insurance reform can we begin the process of real healthcare reform.”

Nancy R. Terry, medical writer and editor, Jackson Heights, New York

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Neutralizing HIV: Shown here are HIV viruses budding from an immune cell.
Credit: C. Goldsmith

A diverse group of antibodies may work together to neutralize the virus, suggesting a new approach to vaccination.

MIT Technology Review, March 18, 2009, by Lauren Gravitz — The human immunodeficiency virus (HIV) is infamous for being a wily opponent, evolving faster than the immune system can keep up with it. Even now, 25 years after the virus was discovered, efforts to create a vaccine against it have fallen flat. While scientists have engineered antibodies that provide broad protection against the virus, vaccines designed to trigger the production of these antibodies work in monkeys but fail to elicit any immunity whatsoever in humans. Now new research shows that vaccines might do better if they could stimulate the body to produce not one of these “super” antibodies but hundreds of milder ones that act, en masse, to take down HIV.

Researchers from Rockefeller University examined the blood of six “slow progressing” HIV patients–people who can be infected for a long time without getting sick because their bodies are able to sufficiently control the virus. Using a novel technique to identify HIV-antibody-producing cells in the blood, and then another new method to isolate the antibodies themselves, the researchers found 433 different antibodies from these patients that can bind to a particular protein–called gp140–that the virus needs in order to infect immune cells. Many of these human isolated antibodies were capable of neutralizing some strains of HIV in lab tests.

Previous efforts to engineer an HIV vaccine have targeted this protein, but failed to stimulate the human immune system to produce any of the four broadly neutralizing antibodies described to date. The newly discovered group of antibodies, however, provides insight into the body’s natural response to the virus. Unlike the man-made antibodies, none has a great individual impact. But together, they can successfully hold the virus in check. “Not a single one of them is like the ‘fantastic four,’ but the body doesn’t make the fantastic four,” says Michel Nussenzweig, a professor of molecular immunology at Rockefeller University, who led the research. “So maybe what this says is that the kind of vaccine you want is one that will make all these other little guys that, together, will be effective.” The research was published online in the journal Nature on Sunday.

“They essentially rescued the immune memory of six individuals infected with HIV into a test tube,” says Dennis Burton, an immunology professor at the Scripps Research Institute and head of the newly formed HIV Neutralizing Antibody Center. “It’s a major tour de force of immunology.” But he notes that while the study is a great leap forward, there’s still some distance to go before researchers completely understand how people’s immune systems respond to HIV. “There’s still many outstanding problems and issues–we’ve got some of the pieces of the jigsaw puzzle, but there’s a lot of pieces still missing,” Burton says.

Finding such a broad array of antibodies was a huge task that required a novel set of techniques. First, the researchers had to identify the immune cells that bound to gp140 by staining them with HIV proteins. Cells that tested positive were separated out, and the scientists created a “library” of the cells’ DNA fragments. From these fragments, they cloned all the antibodies, expressed them in a new batch of cells, purified out the secreted antibodies, then tested them for their ability to bind to gp140 and to determine whether they inhibited virus replication.

“It’s an impressive amount of work,” says David Montefiori, the director of the Laboratory for AIDS Vaccine Research and Development at Duke University Medical Center. “Nothing of this magnitude has even been attempted before.”

The newly isolated antibodies themselves are unlikely to be an effective protective treatment or therapy. While some of the 433 antibodies can neutralize some strains of HIV, taken together, they cannot broadly neutralize all relevant strains. And the virus would continue to mutate, likely rendering the antibodies’ neutralizing powers less potent over time.

What life on another planet might look like, and other tidbits.

MIT Technology Review, March 18, 2009, by Emily Singer — The future of life and the origin of life are two big questions that often get intertwined. Attempts to create life from scratch could shed light on how it evolved, and on how it might be engineered in the future. Several prominent scientists, including genomics pioneers Craig Venter and George Church and biologist Jack Szostak, reflected on these questions and more at the Future of Life symposium at Harvard last weekend. Here’s a sampling of interesting tidbits from their talks.

Re-creating alien life:

Harvard’s Szostak has been a pioneer in attempting to re-create the origins of life. His lab has shown that lipids and RNA can spontaneously assemble under conditions resembling those of early Earth, and it’s now trying to create RNA that can replicate–another prerequisite for life. Szostak’s team is also thinking about what life might look like beyond Earth. “We want to see if we can make living systems by design that can live in totally different environments,” he said at the conference. One of Mars’s moons, for example, has a lake of liquid hydrocarbons, such as methane, rather than liquid water. So Szostak’s lab is attempting to engineer life that can survive in these conditions. The researchers have so far been able to make membranes in these solvents.

Engineering long-lived rodents:

With its moist pink skin and immense buck teeth, the naked mole rat is no beauty. But what it lacks in comeliness, it makes up for in longevity. The rodent can live for nearly 30 years–more than 10 times longer than its cuter, furrier cousin, the mouse. A new project in George Church’s lab will try to figure out why. Church will use novel gene transfer methods to introduce into lab mice approximately 30 genes that are thought to play a role in longevity in the naked mole rat.

Scouring the planet’s genetic diversity:

According to Craig Venter, most of the world’s genetic diversity has yet to be discovered. During his envious trip around the globe–spent on his yacht collecting microbes in water samples from Mexico to Nova Scotia–Venter said that 85 percent of the genome sequences he and his team collected every 200 miles were unique. While gene discovery in mammals is largely saturated (meaning that most gene families have already been discovered), “you can find new gene families from bacteria just about everywhere you look,” he said.

Venter and his team haven’t just been sequencing sea life: they are examining the genomes of the microbial inhabitants of our bodies as well. Case in point: the approximately 1,000 species of microbes in our mouths contribute 4,000 genes. Compared with the approximately 20,000 genes in the human genome, that’s a significant contributor to genetic diversity, said Venter.

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The Polar North, September 2008. The loss of the reflectivity of the Arctic sea ice will affect the lives of everyone and every living thing on Earth.

Risk of extreme climate change accelerating

Posted By admin On March 16, 2009 @ 3:54 pm In Arctic sea ice, Dangerous Climate Change, Glacial Melt, Global Climatic Disruption, Global Resources, IPCC, Melting Permafrost, Ocean Acidification, Tipping Points |

COPENHAGEN CLIMATE CHANGE CONGRESS NEWS

[1] Andrew Glikson
Australian Earth and paleoclimate scientist

The key message of the concluding communication from the Copenhagen Climate Science Congress, attended by some 2000 scientists and other, 11-12 March, 09, reads: ([2] http://climatecongress.ku.dk/newsroom/congress_key_messages/):

“Recent observations confirm that, given high rates of observed emissions, the worst-case IPCC scenario trajectories (or even worse) are being realized. For many key parameters, the climate system is already moving beyond the patterns of natural variability within which our society and economy have developed and thrived. These parameters include global mean surface temperature, sea-level rise, ocean and ice sheet dynamics, ocean acidification, and extreme climatic events. There is a significant risk that many of the trends will accelerate, leading to an increasing risk of abrupt or irreversible climaticshifts.”
([2] http://climatecongress.ku.dk/newsroom/congress_key_messages/)

The worst case scenario of the IPCC-2007 (AR4) is defined as “scenario A1F1″, which assumes global CO2-equivalent emissions (CO2-e = CO2 + methane + nitric oxide) will grow from the current level of about 40 billion ton CO2-e per year (GtCO2-e/year) to near 130 GtCO2-e/year through the 21st century ([3] http://www.ipcc.ch/pdf/assessment-report/ar4/syr/ar4_syr_spm.pdf).

The consequences of this IPCC Special Report on Emission Scenario (SRES) is a mean global temperature rise of between about 2.4 and 6.5 degrees Celsius by 2090-2099 relative to the period 1980-1999, taking the albedo effects of atmospheric aerosols (industrial haze, dust, carbon particles) into account. However, the IPCC-2007 AR4 Report takes only limited account of carbon cycle feedback effects and ice/water interaction feedback effects in raising global temperatures. It also acknowledges limited information regarding ice sheet melt and breakdown dynamics.

Last time mean global temperatures reached 2 to 3 degrees Celsius above present levels, in the mid-Pliocene (3 million years ago), an event associated with CO2 levels of about 400 parts per million, polar regions were heated by near-8 degrees C and sea levels have risen by 25+/-12 meters relative to the present. This represents near-total melting of Greenland and west Antarctica ice sheets (Robinson et al., 2008: “Pliocene role in assessing future climate impacts” ([4] http://pubs.giss.nasa.gov/abstracts/2008/Robinson_etal.html).

A rise of mean global temperatures above 4 or 5 degrees Celsius would shift the atmosphere to pre-glacial/interglacial conditions, which dominated the Earth from about 34 million years ago (end-Eocene) (Zachos et al., 2008) [5] http://www.nature.com/nature/journal/v451/n7176/full/nature06588.html

Key message No. 5 of the Copenhagen Congress reads: “There is no excuse for inaction. We already have many tools and approaches: economic, technological, behavioral, management to deal effectively with the climate change challenge. But they must be vigorously and widely implemented to achieve the societal transformation required to decarbonise economies. A wide range of benefits will flow from a concerted effort to alter our energy economy now, including sustainable energy job growth, reductions in the health and economic costs of climate change, and the restoration of ecosystems and revitalization of ecosystem services.”

Whereas at Copenhagen hopes the December meeting of world governments in the same city ([6] http://www.erantis.com/events/denmark/copenhagen/climate-conference-2009/index.htm) will make the difference are limited ([7] http://www.timesonline.co.uk/tol/news/environment/article5870729.ece [8] http://www.timesonline.co.uk/tol/news/uk/article5908377.ece
[9] http://www.timesonline.co.uk/tol/news/environment/article5898045.ece.
the role of climate scientists in explaining the implications of non-decision is critical. According to Senator Christine Milne “Australia’s climate scientists have been remarkably reticent to publicly criticize what they have in private slammed as a totally unacceptable and inadequate target” (11.3.2009) ([10] http://christine-milne.greensmps.org.au/content/media-release/greens-coalition-agree-ets-senate-inquiry-time-scientists-speak-out).

The New York Times, March 2009, by Nicholas Wade — With soaring oratory, President Obama has removed a substantial practical nuisance that has long made life difficult for stem cell researchers. He freed biomedical researchers using federal money (a vast majority) to work on more than the small number of human embryonic stem cell lines that were established before Aug. 9, 2001.

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Easing Restrictions on Embryonic Stem Cells

In practical terms, federally financed researchers will now find it easier to do a particular category of stem cell experiments that, though still important, has been somewhat eclipsed by new advances.

Until now, to study unapproved stem cell lines, researchers had to set up separate, privately financed labs and follow laborious accounting procedures to make sure not a cent of federal grant money was used on that research. No longer. The lifting of such requirements “is just a major boon for the research here and elsewhere,” said Dr. Arnold Kriegstein, a stem cell researcher at the University of California, San Francisco.

Dr. George Q. Daley, who studies blood diseases at Children’s Hospital in Boston, said that he had derived 15 human embryonic stem cell lines using private money, and that for the first time he could now apply for grants from the National Institutes of Health to study these cells. In the last eight years, his lab has moved from 90 percent N.I.H. support to half N.I.H., half private financing. But private money is now drying up, he said, and new N.I.H. support will be particularly welcome.

However, the president’s support of embryonic stem cell research comes at a time when many advances have been made with other sorts of stem cells. The Japanese biologist Shinya Yamanaka found in 2007 that adult cells could be reprogrammed to an embryonic state with surprising ease. This technology “may eventually eclipse the embryonic stem cell lines for therapeutic as well as diagnostics applications,” Dr. Kriegstein said. For researchers, reprogramming an adult cell can be much more convenient, and there have never been any restrictions on working with adult stem cells.

For therapy, far off as that is, treating patients with their own cells would avoid the problem of immune rejection.

Members of Congress and advocates for fighting diseases have long spoken of human embryonic stem cell research as if it were a sure avenue to quick cures for intractable afflictions. Scientists have not publicly objected to such high-flown hopes, which have helped fuel new sources of grant money like the $3 billion initiative in California for stem cell research.

In private, however, many researchers have projected much more modest goals for embryonic stem cells. Their chief interest is to derive embryonic stem cell lines from patients with specific diseases, and by tracking the cells in the test tube to develop basic knowledge about how the disease develops.

Despite an F.D.A.-approved safety test of embryonic stem cells in spinal cord injury that the Geron Corporation began in January, many scientists believe that putting stem-cell-derived tissues into patients lies a long way off. Embryonic stem cells have their drawbacks. They cause tumors, and the adult cells derived from them may be rejected by the patient’s immune system. Furthermore, whatever disease process caused the patients’ tissue cells to die is likely to kill introduced cells as well. All these problems may be solvable, but so far none have been solved.

Restrictions on embryonic stem cell research originated with Congress, which, each year since in 1996, has forbidden the use of federal financing for any experiment in which a human embryo is destroyed. This includes the derivation of human stem cell lines from surplus fertility clinic embryos, first achieved by Dr. James Thomson of the University of Wisconsin in 1998.

President Clinton contemplated but never implemented a policy that would have allowed N.I.H.-financed researchers to study human embryonic stem cells derived by others. Research was able to begin only in August 2001, when President Bush, seeking a different way around the Congressional restriction, said researchers could use any lines established before that date.

Critics said the distinction between the Clinton and Bush policies lacked moral significance, given that each was intended to get around the Congressional ban, based on a religious and moral argument. The proposed Clinton policy amounted to: “Stealing is wrong, but it’s O.K. to use stolen property if someone else stole it.” The Bush policy was: “Stealing is wrong, but it’s O.K. to use stolen property if it was stolen before Aug. 9, 2001.”

Mr. Obama has put the proposed Clinton policy into effect, but Congressional restrictions remain. Researchers are still forbidden to use federal financing to derive new human embryonic stem cell lines. They will, however, be allowed to do research on new stem cell lines grown in a privately financed lab.

Stem cell research is the best known of several avenues of investigation into what is known as regenerative medicine. To regenerate the aging body with its own subtle repair systems, of which stem cells are one component, would be far more effective than the brute methods of drugs and surgery used today.

But scientists are still merely at the threshold of understanding how the body’s 200 different types of cell interact with one another. It seems likely to be years before biologists know all the settings that must be adjusted in a human cell’s chromosomes to make it become a well-behaved cone cell in the retina or a dopamine-making neuron of the type destroyed in Parkinson’s.

Despite the new interest in reprogrammed stem cells, human embryonic stem cells are still worth studying, both to track the earliest moments in disease and to help assess the behavior of the reprogrammed cells.