Many have proposed that retail clinics—which provide health services from a few square feet carved out of grocery stores and pharmacies—could represent a means by which  the poor and uninsured can access health care.

It turns out however, that few such clinics exist in poor neighborhoods.

According to a recent study, retail clinics follow the money to affluent suburbs, just like most businesses and for that matter, most health care providers.

Craig Pollock and colleagues at the University of Pennsylvania matched the zip codes of 930 retail clinics with US census data describing the income and racial makeup of these areas.

They found that only 123 clinics had been set up in areas defined by the Feds as medically underserved. Regions featuring at least one retail clinic had a lower percentage of Hispanic and Black residents, lower family income, and higher rates of home ownership.

The write-up appears in the Archives of Internal Medicine.

“Many people have promoted retail clinics as a cure for access to care for the underserved,” the University of Pittsburgh’s Ateev Mehrotra told the Washington Times. “These findings show that’s unlikely to happen.”

Pollock’s group concluded that financial incentives may be required to lure the clinics to underserved areas. 

Retail clinics feature customer-friendly hours of operation and are usually staffed by nurse practitioners. They give immunizations and treat minor conditions such as skin rashes and upper respiratory illnesses. The services typically run between $40 and $75. Prices are usually posted.

Some, but not all retail clinics accept insurance.  CVS Caremark and Walgreens are the largest operators of retail clinics. Together, they run about 1,200 of them. States with the highest numbers of retail clinics are Florida (with 147), then Texas, California and Illinois.

Harvard scientists have found that as people age to a point where they become eligible for Medicare, the improved access to care it assures is associated with reductions in racial and socioeconomic disparities in health status.

That supports a contention made by many that universal coverage could narrow the US’ appalling gaps in the quality and outcomes of care for non-whites and the poor.
 
Before reaching these conclusions, John Ayanian and colleagues performed observational and quasi-experimental analyses of cross-sectional data from the National Health and Nutrition Examination Survey. Data had been collected between 1999 and 2006 from adults aged 40 to 85 years old.
 
The scientists found that measures of disease control improved significantly across all racial and socioeconomic subsets during the 7-year study period, which had the effect of preserving racial disparities noted at study onset…until that is, people reached an age where they qualified for Medicare.

That’s when the gaps narrowed dramatically.

Once people with hypertension enrolled in Medicare, Black vs. white disparities in systolic blood pressure dropped by 4.2 mm Hg, a 60% reduction.

Similarly, Medicare enrollment was associated with a 70% reduction in Black-white disparities for hemoglobin A1c levels, a measure of diabetes control. There were similar reductions in disparities when people were stratified according to educational status. 

“Universal health insurance may reduce persistent disparities we’ve seen for far too long in Americans from different racial or ethnic groups,” Ayanian told BurrillReport. He’s a professor of medicine and health care policy at Harvard Medical School and Brigham and Women’s Hospital.
 
The write-up is in the Annals of Internal Medicine.

“The results of this study make it clear that guaranteeing access to affordable insurance for all Americans is the essential first step toward…a healthier America,” said Karen Davis, president of the Commonwealth Fund, which funded the study.

Data are filtering in on Massachusetts’ grand plan to extend health insurance coverage to virtually all Bay Staters. The good news is just about everyone’s covered. The bad news is just about everything else.

When it comes to controlling health care costs, the state’s performance has been abysmal. Experts recently predicted that the state will spend $600 million more in 2009 on health care than in 2006, a 42% bump.

Now comes troubling data on a measure of access to care, emergency room visit volume.

In theory, the state’s new law should cut the costly visits because more people have access to PCPs that can either treat health situations before they reach crisis proportions or prevent them altogether.

In fact, ER visits went up 7% and the cost per ER visit jumped 17% in Massachusetts between 2005 and 2007, according to data shared with the Boston Globe.

The fraction of ER visits for non-urgent matters that could have been handled by a PCP remained unchanged at an astonishingly high 47%.

Massachusetts officials said several more years were required before accurate assessments could be made regarding the impact of their law on access to care.

The law actually went into effect half-way through the data collection period used to make the conclusions above, so they may have a point there.

Still, many worry that simply extending health insurance coverage isn’t going to control costs or improve access. They say the state needs to beef up its PCP corps before the program can work.

“Just because you have insurance doesn’t mean there’s a [PCP] who can see you,” said Sandra Schneider, VP of the American College of Emergency Physicians. “I am not surprised that visits went up.”

In 2006, Massachusetts enacted a law that vastly reduced the number of uninsured Bay State residents. There was one slight problem though. Scads of the newly insured couldn’t find primary care doctors to take care of them.

Wait times for routine office visits have soared in some parts of the state to 100 days and many residents have simply given up trying to find one.

These folks end up seeking care in ERs which is what they did before they were covered.

The problem scares the bejeesus out of officials in the Obama administration, who know that if the Big O has his way and 40-50 million Americans acquire health insurance in the blink of an eye, the same problem will play itself out nationwide.
 
What to do? Some suggest bumping medical school enrollment which would begin addressing the problem around the time the Big O wraps-up his second term, and that’s assuming any of the new graduates actually enter primary care.

Others recommend increased utilization of nurse practitioners and physician assistants, but last time we checked all these types are already happily employed, and training new ones is associated with lag time problems of its own.

Solutions with a quicker onset of action include expanding RN-staffed retail clinics with leveraged physician oversight, and opening the doors even more widely to foreign medical graduates.

Some even suggest overhauling the payment structure for physicians in a way that incents specialists to do some primary care.

Assuming policymakers have the stomach to take on physician payment reform in a way that doesn’t cause system-wide costs to skyrocket, the idea won’t go down well with specialists, regardless.

Listen to Peter Mandell, for example. The spokesman for the American Association of Orthopedic Surgeons told the New York Times, “we have no problem with financial incentives for primary care (but) if there’s less money for hip and knee replacements, fewer of them will be done for people who need them.”

In Q4 2008, WellPoint lost 288,000 covered lives, half of which were caused by rising unemployment and lost employee benefits.

“Economic conditions will continue to deteriorate and unemployment will continue to increase,” CEO Angela Braly sighed to analysts at the time. “This will impact commercial membership in 2009.”

She got that right.

The nation’s largest private insurer, which covers nearly 35 million lives, reported last week that it lost nearly half a million more members in Q1 2009, nearly 65% of which were due to layoffs or employees simply opting out of employer coverage.

That jaw-dropper was topped the next day by UnitedHealth Group Inc., the second largest insurer. The Minnesota-based company reported a drop of 900,000 in the number of people enrolled in its commercial health plans.

The news prompted economists to estimate that the uninsured population has swelled by at least 4 million people since the 2007 estimate by the Census Bureau pegged the number at 45.7 million.

The Kaiser Family Foundation estimates for example that for each percentage-point increase in the unemployment rate, the population of uninsured Americans grows by 1.1 million.

The findings were confirmed by Tenet Healthcare, a hospital chain that recently reported a 2% drop, year-over-year, in the number of admissions of patients with private coverage.

“It’s probably not a surprise that with all these people losing jobs, a lot will lose their health insurance,” Paul Ginsburg, president of the Center for Studying Health System Change told the Wall Street Journal.

One month after MinuteClinic struck a heady deal to link EMRs with the Cleveland Clinic and one week before the US government announced a health emergency due to Swine flu, the CVS Caremark subsidiary announced it planned to shutter 16% of its locations during spring and summer, normally the off-season for colds and flu.

Industry experts claimed that poor business performance during these periods represented “a structural flaw” in the retail clinic business model, and predicted a gloomy future for all but those with storefronts in close proximity to, or otherwise affiliated with hospitals and physician groups.

That’s because provider-associated retail clinics have large enough catchment populations to sustain themselves year-round, or at least offset lower off-season traffic with business at other venues and facilities.

MinuteClinic’s decision risks nullifying the very image of convenience that drives success in the first place, according to Tom Charland, CEO of Merchant Medicine, a consultancy specializing in retail clinics.

“You can’t preach convenience and consistency out of one side of your mouth and then have it sort of up in the air as to whether that clinic is open or not,” Charland told AMedNews.

With over 500 stores, MinuteClinic is the largest retail clinic chain in the US. It’s not clear whether other clinic chains will follow suit, or how the Swine flu scare might shuffle the deck.

The retail clinic business is not for the faint of heart.

On average, it takes 3 years before outlets turn a profit, and many fold before then.

CheckUps for example, closed 23 of its Wal-Mart housed clinics in January 2008, and last summer SmartCare shuttered 15 venues which had also been housed in Wal-Mart.

Still, the number of retail clinics continues to rise.

About 1,100 clinics are open today, as compared with only 200 at year end, 2006.

And soon after announcing the seasonal shutdowns, MinuteClinic itself opened several new, year-round locations in Massachusetts.

They’re stocking up on Tamiflu and Relenza as we speak.

Nearly 25% of Americans live at least an hour from an Emergency Department that’s equipped to save lives in the event of a heart attack, stroke, bacterial bloodstream infection or major trauma.

To reach this conclusion, Brendan Carr and colleagues from the University of Pennsylvania School of Medicine queried the National Emergency Department Inventories–USA to identify the location and visit volume for all EDs in the country.

They estimated driving distances, driving speeds and population density, and measured ED access as the total population that could reach any particular ED within specified time intervals.

The scientists determined that 71% of Americans can access an ED within 30 minutes, and 98% can do so within an hour. But many of these facilities can’t handle the life-threatening stuff. Only high volume EDs are staffed, trained and equipped to do that.

In Montana for example, just 8% of the population resides within an hour of an ED that sees at least 3 patients per hour.
 
The write-up appears in the Annals of Emergency Medicine.

“Whether you are bleeding to death from an injury, having a heart attack or a stroke, the common denominator is time,” lead author Brendan Carr told BurrillReport.

The assistant professor of Emergency Medicine and Epidemiology added “in life-threatening emergencies, we must rely upon the system to deliver us to the care that we need.”

“If we knew what services were provided where, we could design a system that would do that everywhere in the country.”
 
The scientists suggest EMTs should be empowered to bypass the closest hospital in lieu of facilities better equipped to handle appropriately sick patients, ED facilities at rural hospitals should be beefed up, and incentives should be offered for physicians to practice in remote locations.

Dr. George Taler makes house calls!

The Washington Hospital Center-based physician belongs to an intrepid tribe of providers that are reviving a lost art one tongue-depressor at a time. 

Back in the 1930s, 40% of all encounters with physicians occurred in the home, but that number dropped to 10% by 1950, and 1% by 1980, according to Helen Kao and colleagues whose article appears in Clinics in Geriatric Medicine.

Patients preferred to visit hospitals and clinics, which were perceived to be modern wonders, jam-packed with gee-whiz diagnostic tools and treatments that became the sine qua non of medicine in the second half of the century.

Or, as Kao’s team put it, “house calls became old fashioned.”

Financial incentives also drove the migration. Physicians who opted for lucrative, technology-driven specialties found themselves tethered to the facility-based machines, while PCPs deduced that they could triple visit counts by having patients come to them rather than the other way around. 

Then, about a decade ago Medicare began facilitating payment to physicians who made home visits to the elderly and chronically ill, and sweetened their reimbursement pot by 50%.

Since then, physician home visits have risen from 1.5 million to 2.2 million.

“There is growing interest,” Constance Row told the Washington Post. The executive director of the American Academy of Home Care Physicians added it’s a “win-win situation for everyone. It is one of those things that patients, their families and caregivers want and also something that (could) save money.”

And ironically, technology–which helped undermine house calls 50 years ago–now assures that physician home visits are more productive than ever.

Nowadays, physicians carry laptops, electronic medical records, portable EKG machines, and ultrasound machines right into the bedroom.

With apologies to GE, Disney and the 8 US citizens who remain optimistic about prospects for our health care system.

Welcome to the US Health Care Carousel of Progress!

Normal carousels just spin ’round and ’round and don’t get you anywhere, but ours is different.

The Health Care Carousel makes progress every year.

And progress isn’t simply moving forward, it’s working together and dreaming and assuring better health care for all.

Progress is the whiz-BANG of an MRI machine in use for the evaluation of a 22 year old with a headache. It’s the drug-induced smile on the face of a woman that became depressed after losing her home to foreclosure.

Progress is the rhythmic lub-dupp of a heart beating normally following a transplant for preventable cardiac disease. It’s the sound of an uninsured child wheezing in a crowded emergency room.

Why, you can hardly imagine all the amazing gadgets they’ve got in ERs nowadays!

Remember the sixties when folks got their exercise doing the Twist? Well, today we keep our cholesterol down with pills!

And our food safety system has never been better.

Our generation may be the first in 300 years to experience a decrease in life expectancy, but think how much worse it would be without $10,000 cancer drugs and blood thinners that prevent complications from hardware we’ve inserted into people’s bodies.

It’s never been easier to find a PCP, and would you believe it? They’re building our city’s 17th PET scanner right where that run-down urban health clinic used to be.

You should hear physicians rave about how those newfangled EMRs save them time.

And progress even has a smell! It’s the smell of money lining the pockets of a hundred-thousand physicians that have been bought off by Big Pharma.

With all these marvels, it’s hard to believe things could get better than they are right now. But as you join us for a spin around our Carousel of Progress, you’ll surely agree. Anything’s possible.

Ethics
In a referenced essay titled, Transparency in the Pharmaceutical Industry, Brain Blogger’s Jennifer Gibson describes how the impending passage of the Physician Payments Sunshine Act has motivated Big Pharma to disclose financial relationships with physicians. She warns there may be adverse consequences from this otherwise laudable development: some physicians will be discouraged from forging socially beneficial collaborations with the private sector.

Last week, the FDA’s Psychopharmacologic Drug Advisory Committee unanimously rejected AstraZeneca’s application to market its atypical anti-psychotic drug Seroquel for generalized anxiety disorder and major depression.

Merrill Goozner at GoozNews applauds the decision, but wonders whether the agency may have left itself open to charges of bias by seating a patient representative on the panel who had lost a son to cardiac arrest while taking the drug. 

Health Care Renewal contributor Roy Poses has reviewed an unseemly side show to the Madoff scandal. The antagonist is Ezra Merkin, a hedge fund director charged with fraud for misrepresenting his investment strategies.

Merkin and Madoff had served on the board of Yeshiva University, which lost $110 million to the Ponzi scheme. Their unholy alliance leads Poses to consider possible negative consequences of having too many financial types on the boards of academic institutions.

Insurance
In the latest chapter of her neverending odyssey to navigate Big Insurance and the health care system generally, Colorado Health Insurance Insider’s Louise Norris describes what happened when her husband needed knee surgery. The savvy couple planned for every contingency, yet still they encountered a system failure in the form of an out of network charge.

Jaan Sidorov at Disease Management Care Blog has proposed a frightening, unintended consequence of health care reform which is that private health insurers might, like AIG, become too big to fail.

Sidorov thinks creation of a new public insurer will prompt a wave of consolidation in Big Insurance, and the remaining behemoths will seek cover in the form of regulatory oversight from the Feds.

Over at The Health Care Blog, Brian Klepper has contributed a wide-ranging historical perspective on efforts by Big Insurance to control health care cost escalation.

After characterizing utilization review and PCP gatekeeper systems as well-intentioned but poorly executed efforts, he proposes that tricked-out workplace-based clinics (“onsite clinics”) may be a solution, and cites facilities on the premises of Cigna as shining examples.

He concludes however, that the proof will be in the pudding. After all, everyone thought UR and gatekeepers were good ideas, too.

There’s a great, big, beautiful tomorrow,
Shining at the end of every day

There’s a great, big, beautiful tomorrow
And tomorrow’s just a dream away

Man has a dream and that’s the start
He follows his dream with mind and heart

When it becomes a reality
It’s a dream come true for you and me

Access, Cost Escalation
InsureBlog’s Bob Vineyard reviews interim results from Massachusetts’ much publicized universal health care plan, which many believe should be a model for national health care reform.  The plan has left at least 200,000 state residents uninsured while utterly failing to rein in costs. And to make it right Vineyard warns, Bay state lawmakers are either going to have to squeeze providers even more or (gasp!) ration care.

At Managed Care Matters, Joe Paduda has posted a dispassionate, fact-based treatise designed to calm the knee-jerk anxiety that normally surrounds concepts like universal health care and rationing.

He points out for example that Big Insurance already engages in rationing through pre-certification processes, provider agreements and so forth.

He then dismantles the claim that universal health care leads to longer waiting times for care. Paduda concludes that if we manage to institute such programs, “access will go up and waiting times may well go down.”

Amid a fusillade of jabs and an occasional uppercut to the jaws of the Big O and his admirers, JD Bell reveals over at It Takes Work that Howard Dean has launched a web site to promote his own vision for health care reform.

According to Bell, Dean is concerned the Big O is waffling on his campaign promises, and wants nothing more for the American people than what Obama promised them prior to November 4.

Writing for Workers’ Comp Insider, Jon Coppelmen observes that employers’ most effective tools for managing comp losses vanish after they lay off employees. The trust, indeed the entire relationship between employer and former employee, is lost. This leaves claims adjusters, who are typically overworked and not properly incented, to manage workers’ compensation costs.

With unemployment approaching historical levels, Copplemen’s antidote, three proactive steps employers can take to manage the regrettable situation, is timely indeed.

Quality and Safety
A recent NEJM article on the cost and quality implications of readmissions has prompted Maggie Mahar to review the subject over at Health Beat. Mahar summarizes the views of White House budget director Peter Orszag and others on the matter, and then offers several home-grown suggestions about how to tackle the problem.

Mahar explores for example, the concept of bundling payments to hospitals and physicians who are responsible for care immediately following discharge, and directing special attention towards states in which the readmission problem is particularly severe.

Novo Nordisk had been prepared to discuss cardiovascular complications at last week’s FDA advisory panel meeting regarding liraglutide, its new diabetes drug, but instead the drug’s association with rare tumors of the thyroid drove the discussion.

Jeffrey Seguritan at Nuts for Healthcare summarizes the surprising development then expands into an informative discussion of the efficacy with which drug trials assess cancer risk.

There’s a great, big, beautiful tomorrow,
Shining at the end of every day

There’s a great, big, beautiful tomorrow
And tomorrow’s just a dream away

Man has a dream and that’s the start
He follows his dream with mind and heart

When it becomes a reality
It’s a dream come true for you and me

Legal
HealthBlawg’s David Harlow is generally supportive of the deal struck by CVS and Google, in which prescription data from the retail pharmacy giant can now be directly imported into Google Health, the search giant’s personal health record. On balance Harlow says, the gains in patient safety and quality outweigh the increased risk of breaches in patient confidentiality, at least for people who have not recently given birth to octuplets or are named Britney Spears.

Health IT
When a healthcare journalist came down with a touch of bronchitis, he blew off the last vendor meeting at HIMSS and went to the doctor.

His encounter underscored a yawning gap between today’s reality of spotty EMR adoption and a future-state of nirvana that has been promised by so many. 

The real-life story appears at Niel Versel’s Healthcare IT Blog.

We hope Neil feels better, by the way.

At the Health Business Blog, David Williams has posted a transcript of his interview with Wayne Guerra, the co-founder and chief medical officer of Healthagen, the maker of a way-cool iPhone application known as iTriage.

In the interview, Guerra explains how his mobile triage and health information tool can be used, the types of people most likely to benefit from it, and how he hopes to monetize the idea.

The Healthcare IT Guy invited Paul Nuschke, a software design expert at the IT consultancy Electronic Link to comment on the subject of EMR usability. Nuschke asserts there are three keys: the EMR should be easy to learn, efficient, and prevent errors automatically.

Nuschke appends a series of baffling screen shots which make it laughably clear that some of the mainstream players in the space aren’t quite there yet.

Policy
Over at the Healthcare Economist, Jason Shafrin asks, “Why have disability rates decreased?” To answer the question, Shafrin reviews a scholarly piece from the National Bureau of Economic Research. He notes that the apparently heartening trend has occurred despite an increasing burden of illness in the general population. The beneficial trends, he concludes, are attributable primarily to non-medical advances like “internet shopping, amplifying devices for phones and street ramps” rather than health care-specific interventions.

Damn, we thought we had something there for a moment.

Actual US Health Care Carousel of Progress:

As a result of their remarkable 3-year effort, Massachusetts lawmakers increased by 430,000 the number of people with health insurance in the state.

That leaves only 2.6% of Bay Staters uninsured, which is one-sixth the national average and by far the lowest rate in the nation.

Not only that, the legislators, working in synchrony with then Governor Mitt Romney, enacted the law faster than a Harvard Club Eight.

They pulled off the coup by deferring for another day the matter of controlling health care cost escalations which everyone knew would accompany the move.

That other day is here.

Massachusetts will spend $600 million more in 2009 on health insurance than it did in 2006, a 42% bump.

So Governor Deval Patrick has decided to completely overhaul the process by which the state’s insurers reimburse providers.

His proposal emphasizes prevention and chronic disease management in lieu of the current system, which pays fee for service.

If he pulls it off, the achievement would be every bit as audacious as the universal coverage plan itself.

Massachusetts after all, boasts more physicians per capita than any other state, and its vaunted academic medical centers have cut sweet deals with insurers.

Patrick recently chided the latter. “Frankly,” he told the New York Times, “it’s hard for the average consumer to understand how some of these companies can have the margins they do and the annual increases in premiums that they do.”

Patrick’s persuasive powers have worked, at least temporarily. Insurers who want in on the state’s subsidized insurance program submitted bids for 2009 that were so low, officials reported they can keep premiums flat this year.

But policy experts argue that to truly control cost escalations, government needs to cap budgets and yes, ration care.

“Really controlling costs requires just stopping spending,” Brandeis health policy expert Stuart Altman told the Times.

In January, the Hawaii Medical Service Association began offering Internet-based “house calls” in which physicians communicate with patients using streaming video, text chat or phone.

HMSA-covered patients pay $10 for a 10-minute exchange but anyone can get the same 10 minutes in heaven for $45.

Boston-based American Well is choreographing that show, and now other companies have entered the market.

SwiftMD offers services in the New York-New Jersey area and TelaDoc is giving it a go in Dallas.

They all have immediate plans to expand, according to the Wall Street Journal.

They have to be careful though since physicians’ licenses to practice medicine are good only for the issuing state.

And the scope of practice matter is dicey for the new tool, so the companies are going slowly.

SwiftMD for example lists on its site the ailments in its wheelhouse: allergies, colds and flu, rashes, things like that.

The very young and very old are not eligible, nor are those with pregnancy-related issues or serious mental health issues like psychoses.

Big Apple resident Leah Light received a subscription to SwiftMD as a gift from her mom.

Light takes prescription meds for an anxiety disorder.

She recently used the service to refill her prescription.

The online visit lasted 55 minutes and cost $55 with a discount.

 Last time she did things the old fashioned way. The doctor visit was time-consuming and set back the uninsured graduate student $260.

“I feel reassured (that) if I need to talk to a doctor, I can without having to blow my food budget for a month,” Light told the Journal. “It makes me feel a lot better.”

With the dentist shortage nearing crisis proportions in Maine, 2 of the state’s primary care residencies have begun to train physicians how to do simple dental procedures like lancing abscesses and pulling teeth.

The Pine Tree state has 4 times more physicians than dentists and that means there’s  only one dentist for every 2,300 people.

The national average is a dentist per 1,600 people.

“Doctors typically say, ‘say aah,’ take a look at the back of the throat and are done,” William Alto told the New York Times.  Alto is a physician at the Maine Dartmouth Family Practice Residency in Fairfield, home to one of Maine’s dental clinics for medical residents.

Maine is a largely rural state and dental school grads are even less prone to opt for such practice settings than their med school brethren. It doesn’t help that the state has no dental schools; the closest ones are in Boston, an hours’ drive with a tailwind from the state’s southernmost point.

Since Maine’s dental training programs began in 2005, 2/3 of residents graduating from these particular programs have set up shop in rural or remote areas.

“I see dental complaints all the time,” Andrew Fletcher confirmed for the Times. Fletcher learned some dentistry during his medical residency and now works up near the Canadian border.

“It’s mostly Medicaid patients who don’t have money to see dentists,” he added.

The Maine Dental Association supports the program but would rather recruit real dentists to the state. Said executive director Frances Miliano, “medical residents are only going to be doing this in dire circumstances. It’s not a total solution by any means.”

The American Cancer Society has reported yet again that African-Americans are more likely to develop and die from cancer than all other groups.

Cancer mortality in black men and women is 33% and 16% higher than in whites respectively, and these yawning gaps haven’t closed a bit since at least 1981, according to Ahmedin Jemal, a co-author of the report.

A key reason for the disparity is that whites tend to get diagnosed at an earlier stage in the disease, when chances for a cure are higher.

But it’s also true that blacks are less likely to receive high-quality treatment, Peter Bach told USAToday.

The Sloan-Kettering oncologist had shown in 2004 that physicians treating black cancer patients were less likely to be cancer specialists and to have access to the latest diagnostic imaging facilities.

Blacks also tend to have lower educational levels, and that makes a big difference regardless of race. In the ACS study, cancer mortality for people with a high school education or less was twice as high as that for people who attended college.

Earlier studies have shown that cancer patients with low educational levels experience significantly longer delays between diagnosis and onset of treatment, as well.

And if that’s not enough, blacks tend to exercise less and are more likely to be obese than whites. These are both major risk factors for cancer. And they receive fewer colonoscopies and other cancer screening tests, and on and on and on.

“This study shows a real disparity in mortality between the haves and the have-nots in this country,” Jemal concluded.

In 2005, Wal-Mart employees had to work 2 years before qualifying for the company health plan, which most considered to be an expensive joke, anyway.

Then, an activist group publicized a confidential company memo saying that health expenses could be cut by not hiring sick people.

This was going down just when towns were protesting store openings, unions were underwriting nasty campaigns, teachers were telling students to take their back-to-school business elsewhere and the company’s stock price was languishing.

But the world’s largest company has made great strides since then.

First, Wal-Mart cut the wait to enroll in the health plan to one year for part-timers and 6 months for full-timers. That made 50,000 more employees eligible in one year.

Then it expanded the menu of insurance coverage options and extended to some employees a credit of up to $500 to offset any health-related expense.

Next, it extended its popular $4 generic drug plan from the 350 drugs available to consumers to greater than 2,000 for employees.

The retailer subsequently cut a preferred-provider deal with Mayo Clinic of all places to cover transplant services for its employees.

The company’s latest foray, Life with Baby, targets premature birth rates among Wal-Mart employees, which are twice the national average.

Expecting moms get paired with a nurse who advises them on diet, smoking, stress reduction and the like. Lactation counseling and vaccination programs are available to moms after that.

“Wow, it was really good. It helped me so much,” Cristina Majano told the Washington Post. The 23-year-old new mom works for Wal-Mart in Virginia.

Nowadays, only 5.5% of Wal-Mart employees lack health insurance. That’s much lower than the national rate, which is 18%.

Nice job fellas!

Hurricane Katrina was hell on Charity Hospital, but things haven’t improved much since the day it left patients stranded in sweltering, unsanitary conditions with no power and vanishing supplies of water, food and medicine.

Charity was the place where caregivers stored bodies in hallways because the morgue was flooded, and made horrible decisions about patients for whom they could not comfort, let alone care for properly.

It’s been 3 ½ years since Katrina and now the ghost of Charity stands in silence, surrounded by a chain-link fence and barbed wire, boarded up like a set for a B-grade horror movie.

Until the storm, the 70-year old facility had been the go-to place for the city’s poor and uninsured. It was the only Level One trauma center in town and by far the most important site for training new physicians.

But plans to replace the gigantic structure and restore these services are dead in the water. The hang-up according to USA Today, is money.

Louisiana requested $492 million in disaster aid from the federal government. It wants to pick up the balance on a $1.2 billion downtown medical center.

But FEMA contends Charity was neglected and in disrepair before the storm. Disaster aid doesn’t cover that, so it countered $150 million, or $51 million more than what it calculated were the costs of storm-related damage.

Nothing’s going to happen until the stand-off is settled, according to LSU’s general counsel Raymond Lamonica. The dispute is likely headed to court.

Meanwhile, the state is focusing on site-designs and buying land for a new Charity. “That’s going to take a couple of years,” Lamonica said. “Hopefully by then we’ll have our money.”

American Well, a Boston-based start-up that facilitates Internet-based physician “house calls” went live on Jan 15 with its first customer, the Hawaii Medical Service Association.

The archipelago’s sole Blue-Cross Blue-Shield licensee in turn plans to assure the service is available to every state resident, including those who are uninsured.

The service should appeal to those who don’t want to wait to see a physician or waste time commuting to the doctor’s office. It seems particularly well suited for patients needing medication refills or a look-see following surgery, and for elderly folks who are comfortable with computers.

Hawaii seems an ideal first venue for American Well’s online doctor service because island geography frequently complicates access to providers, and because the state lacks providers in remote areas.

During the encounter physicians can, ideally, access patients’ medical histories. For example, a patient using Microsoft’s HealthVault personal medical record can permit the physician to access the information.

Some worry what will happen because physicians can’t detect or assess physical findings using the new medium, but Robert Sussman has been trying it for awhile and has some perspective.

“It’s a tool to help doctors do better, the way a stethoscope is a tool,” he told the New York Times. “You still have to use your common sense.”

And at times it can facilitate triage decisions better than a phone conversation. Physicians for example, can see whether a febrile infant is lethargic and hence needs to be seen or is alert and thus may not have to come in.