26 February 2010

Six Important Facts About Avandia

US News and World Report

Controversy over the drug is swirling again. What should you do if you’re taking it? 

To the chagrin of many diabetics, the medication Avandia is back in the news because of its possible link to heart problems. A Senate Finance Committee report released on Saturday says that the drug's manufacturer, GlaxoSmithKline, knew the type 2 diabetes drug had possible harmful cardiac effects several years before a 2007 New England Journal of Medicine study initially raised concerns about Avandia. GSK, for its part, says in a press release that it rejects the report's findings, adding that the committee's conclusions on the safety of Avandia are "based on analyses that are not consistent with the rigorous scientific evidence supporting the safety of the drug." GSK also released a 30-page rebuttal on Wednesday detailing its objections to the Senate Finance Committee's report.

The latest news has some people who take Avandia scratching their heads. "This has created a tremendous degree of uncertainty in our patients," says Robert Vigersky, president of the Endocrine Society and director of the Diabetes Institute at Walter Reed Army Medical Center. "We are recommending that nobody stop this drug precipitously on their own [and] that they speak with their [healthcare] provider." Below are some common questions about the medication, including more of what you should—and shouldn't—do if you're currently taking Avandia.

What are the concerns about heart safety and Avandia?
The Record trial, published in June 2009 in the Lancet and sponsored by GSK, found that Avandia seemed to increase the risk of heart failure in certain patients but didn't find any added risk of heart attack or death. That's in contrast to some, but not all, other studies. A 2007 meta-analysis, which was published in the New England Journal of Medicine and prompted the flurry of concern about Avandia, found that people taking the drug had a higher risk of heart attack and death from cardiovascular causes. And another study, published in November 2008 in the Archives of Internal Medicine, found that the risk of death and heart failure for older people with diabetes seemed to be greater in those taking Avandia than in those taking Actos, another medication in the same class.

But none of these studies have produced definitive conclusions. "We actually don't know a lot more now than we did in 2007," when the NEJM analysis was published, says Vigersky, who doesn't accept funding from pharmaceutical companies. But the Record study does suggest that the drug "may not be as risky as had been suggested in that [2007] study," he says, adding that it was the "only study designed as a prospective, randomized, controlled trial to ask the question, 'Is this drug safe in terms of cardiovascular effects?' " The other studies, done retrospectively, observationally, or as a meta-analysis, "don't have the power to really make conclusions that are certain" because of how they were designed or how the data were analyzed, Vigersky says.

What should I do if I'm currently taking Avandia?

First and foremost, don't stop taking your medication without first talking to your healthcare provider. Ask your doctor any questions you have about continued use of the medicine (or, if you so desire, whether it's possible to switch to another drug), and read the medication guide that your pharmacy dispenses with your prescription to fully understand the benefits and risks of Avandia. Lastly, the Food and Drug Administration asks that you report any side effects you believe are associated with the drug to the agency's MedWatch program.

Why can't I stop taking the medicine first before going to see my doctor?
There are some key reasons not to stop taking Avandia without talking to your doctor first. "What we know is that untreated or uncontrolled diabetes carries a substantial risk of complications," says David Kendall, chief scientific and medical officer at the American Diabetes Association. All medications have the potential for harmful side effects, he says, but the risks of uncontrolled diabetes mean you shouldn't chance changing your medication regimen without a doctor's OK. If left untreated, type 2 diabetes can lead to hyperglycemia (high blood sugar levels), causing frequent urination, increased thirst, and in extreme cases, diabetic coma.

Do I have other options if I want to stop taking Avandia?

Yes. Takeda Pharmaceuticals' Actos, a drug in the same class as Avandia, "works in what we think is a similar fashion," Kendall says. The labels for both Avandia and Actos contain warnings that the drugs may cause or exacerbate congestive heart failure, but there is no evidence so far that Actos causes heart attack, angina, stroke, or death, as is the concern about Avandia.

More definitive answers on the safety of Avandia and Actos may come from a large GSK-sponsored and FDA-mandated clinical trial called TIDE, for which the drugmaker is currently enrolling participants, but even that is not without controversy because of the possible heart risk for study subjects. "[We] really have to know what the risks are," says Vigersky.

When will the government know more about Avandia's safety?
The FDA says it is reviewing information on Avandia's safety and that no recommendations have been made so far. The agency plans to hold a public meeting in July when the review is finished, and at that time, it will detail the known information about Avandia's heart-related safety and update the public on the risks and benefits of the drug.

Do I need to get my heart checked out if I've been taking Avandia for some time?
Because diabetes itself carries a risk of cardiovascular problems, it's important to know where you stand on heart-related risk factors whether or not you take Avandia. In fact, for those with diabetes, the risk of a heart attack is the same as that for a person who has already had a heart attack, according to MedlinePlus. Because of this, people with diabetes should know their blood pressure and cholesterol levels, Kendall says.

24 February 2010

A Danger in Daily Aspirin?

The Wall Street Journal

If you're taking a daily aspirin for your heart, you may want to reconsider.
For years, many middle-aged people have taken the drug in hopes of reducing the chance of a heart attack or stroke. Americans bought more than 44 million packages of low-dose aspirin marketed for heart protection in the year ended September, up about 12% from 2005, according to research firm IMS Health.

Now, medical experts say some people who are taking aspirin on a regular basis should think about stopping. Public-health officials are scaling back official recommendations for the painkiller to target a narrower group of patients who are at risk of a heart attack or stroke. The concern is that aspirin's side effects, which can include bleeding ulcers, might outweigh the potential benefits when taken by many healthy or older people.

"Not everybody needs to take aspirin," says Sidney Smith, a professor at the University of North Carolina who is chairing a new National Institutes of Health effort to compile treatment recommendations on cardiovascular-disease prevention. Physicians are beginning to tailor aspirin recommendations to "groups where the benefits are especially well established," he says.

Doctors generally agree that most patients who have already suffered a heart attack or ischemic stroke, the type caused by a clot or other obstruction blocking an artery to the brain, should take regular low-dose aspirin. But for people without heart disease, the newest guidelines from the U.S. Preventive Services Task Force spell out much more clearly than before when aspirin should be administered.

The guidelines, announced last year, suggest aspirin for certain men 45 to 79 years old with elevated heart-disease risk because of factors like cholesterol levels and smoking. For women, the guidelines don't focus on heart risk. Instead, the task force recommends certain women should take aspirin regularly if they are 55 to 79 and are in danger of having an ischemic stroke, for reasons that could include high blood pressure and diabetes.

The panel urged doctors to factor in conditions that could increase a patient's risk of bleeding from aspirin, which tends to rise with age. The group didn't designate a dose, but suggested that an appropriate amount might be 75 milligrams a day, which is close to the 81mg contained in low-dose, or "baby," aspirin. The task force didn't take a position on aspirin for people who are 80 and older because of a lack of data in this age group.

Other medical researchers dispute the idea that there should be different guidelines for men and women. Still, many experts agree that doctors may have been recommending aspirin to people for whom the risks might outweigh the benefits.

Aspirin acts as a blood thinner, which is believed to account for much of its benefit of protecting against heart attacks and strokes. But that same action, along with a tendency to deplete the stomach's protective lining, can lead to a danger of gastrointestinal bleeding and possibly bleeding in the brain.

The task force issued its latest guidelines after reviewing the evidence from a number of studies on aspirin's benefits and risks. The recommendations update the panel's previous guidelines from 2002, which were more broadly written. Those suggested aspirin use for people of any age who were at elevated risk of heart disease.

"We would like doctors to re-look at their patients who are on aspirin and consider recommending stopping it where the chance of harm outweighs the benefit," says Ned Calonge, a Colorado public-health official who serves as the task force's chairman. He notes, however, that in studies of healthy people taking aspirin, the actual rates of bleeding and of prevented heart attacks were very low.

Not all patients accustomed to taking aspirin will want to stop. Maxine Fischer, 55 years old, recently figured out that under the new U.S. guidelines, she wouldn't be encouraged to continue with the drug. Using an online calculator, which factored such data as her age, blood pressure and medical history, she learned she had just a 1% likelihood of a stroke in the next 10 years. Under the guidelines, only women in her age group with at least a 3% or higher stroke risk should take aspirin.

Ms. Fischer, who works as a manager for seniors' lobby AARP in San Diego, has taken aspirin daily for two years after reading it could reduce the risk of stroke. For the moment, she says she'll keep it up, partly because she's more worried about strokes than ulcers. Strokes are "the big scary thing," she says.

Other patients say they would stick with aspirin because of other benefits attributed to the drug; past research has suggested that regular aspirin may reduce the risk of colon cancer, for instance. Virginia Douglas, 64, a retired trade-association executive, takes aspirin a few times a week. In addition to the possibly reduced risk of stroke, Ms. Douglas hopes to avoid colon cancer, which affected her father and grandfather. "There's always a new study with a new recommendation," says Ms. Douglas, of Sacramento, Calif. "You have to do what's best for you."

In a separate analysis, published in medical journal Lancet last May, an international group of scientists reached a broadly similar conclusion as did the U.S. task force—that doctors may have been recommending aspirin too widely. "You really have to have a clear margin of benefit over hazard before you should be treating healthy people," says Colin Baigent, a professor at Oxford University who coordinated the Lancet analysis.

Still, the Lancet authors disagreed with the U.S. panel on some important details, particularly about who should be taking aspirin. The two groups examined evidence largely from the same studies of the drug, although the international team analyzed the data differently. In the end, the international team of scientists, unlike the U.S. officials, concluded that aspirin's effects on men and women were mostly the same.

Another disagreement between the two groups also emerged: The U.S. task force said that age is the biggest factor determining a person's risk of internal bleeding from aspirin. But the international team said other factors, such as diabetes and high blood pressure, also play a significant role. Unfortunately, the scientists noted, the same factors that increase patients' risk of bleeding also increase their risk of developing heart disease. This, in turn, can make it more difficult to calculate whether the benefits of aspirin would outweigh the risks of side effects.

The U.S. task force responded with a letter to the Lancet, defending its finding that men and women's results did appear different. There is a "wealth of evidence that men and women have different cardiovascular disease manifestations and respond differently to aspirin," the letter said. The panel also reiterated its position that bleeding risk is best parsed by age.

Amid the debate, some individual doctors are finding their own position. Rodney Hayward, who codirects a Veterans Affairs research center in Ann Arbor, Mich., says he's not convinced that aspirin's effects on men and women are so different. He says he continues to recommend aspirin for certain patients of both sexes with significant heart risk.

23 February 2010

Music Boosts Brain Development

One India

Music training proved to have profound effects in shaping a growing child's brain and sensory systems. So the experts in neuroscience advice music to be a main stay of K-12 education. They also advice the cash-strapped schools, not to make the major mistake by cutting music from K-12 Education.

Music training is beneficial for processing music stimuli. It will enhance the brain stems' sensitivity to the speech sounds.

So music study can be an effective strategy in helping typically developing children who is healthy with the neural aspects. Music is equally helpful for the children with developmental problems like dyslexia or autism.

“Playing an instrument may help youngsters better process speech in noisy classrooms and more accurately interpret the nuances of language that are conveyed by subtle changes in the human voice," says Nina Kraus, Hugh Knowles Professor of Neurobiology, Physiology and Communication Sciences at Northwestern University.

22 February 2010

N.J. Doctors Gain Easier Access to Paperwork Via Web


Two trade groups for the health insurance industry carried out some reform of their own Thursday by launching a statewide program that will make it easier and less expensive for doctors to provide care to their patients.

The program will provide doctors’ offices with a single way of accessing dozens of different health plans administered by five major insurers, including Aetna, UnitedHealthcare and Horizon Blue Cross Blue Shield New Jersey.

The scope of the program, which is similar to one launched earlier in Ohio, is enormous because the five insurers represent roughly 95 percent of all New Jersey residents with private health insurance.

Even as the prospect of national health care reform remains up in the air, major insurance providers continued to move ahead on an objective of their own: to simplify and streamline the administrative issues, such as billing and specialist referrals, that constantly tie up and tax doctors’ offices.

The program works by using a single website operated by Cambridge, Mass.-based Navinet, which is the nation’s largest healthcare communications network.

"This makes the process much more efficient,’’ said Thomas Ortiz, a family doctor in Newark. "Doctors always complain that they’re dealing with 50 different insurance companies with 50 different methodologies. You can understand how a standardized process would improve the bottom line.’’

The program, which is sponsored by America’s Health Insurance Plans and the Blue Cross and Blue Shield Association, will be permanent. After the first year, it will be evaluated before it is rolled out in other states.

"The ultimate goal is to have state-wide or regional-wide portals that span the country,’’ said Susan Pisano, spokeswoman for America’s Health Insurance Plans.

Christy Bell, senior vice president of healthcare professional services management at Horizon Blue Cross Blue Shield New Jersey, said Thursday during a conference call announcing the program that one physician estimated his office spends between $60,000 and $100,000 a year just handling administrative issues — or required paperwork.

"We think we can remove a quarter to a third of those costs through streamlining and standardization,’’ Bell said.

The administrative work inside a physician’s office ranges from making telephone calls and sending faxes to specialist’s offices to verifying a patient’s coverage and co-pay information. It involves navigating healthcare data migration among dozens of insurance plans which require their own security and log-in codes.

"This,’’ Ortiz said, "will eliminate a lot of the hassles for primary care physicians.’’

19 February 2010

Ibuprofen May Help Stave Off Parkinsons

Business Week
Finding suggests need to look closer at the disease as inflammatory, expert says

Regular use of ibuprofen, a common anti-inflammatory drug, significantly lowers the risk for developing Parkinson's disease, Harvard researchers report.

People who took three or more tablets a week showed a 40 percent lower risk than those who didn't take the common pain reliever, their study found.

Study author Dr. Xiang Gao, an instructor and epidemiologist at Harvard Medical School and Brigham and Women's Hospital in Boston, said the findings are important for anyone at increased risk for Parkinson's because most people with the disease eventually become severely disabled.

"There is thus a need for better preventive interventions," Gao said. "In this context, our findings regarding the potential neuroprotective effect of ibuprofen, one of the most commonly used analgesics, on Parkinson's disease may have important public health and clinical implications."

Parkinson's is a disease that affects nerve cells in the brain that control the movement of muscles. It affects an estimated 1 million people in the United States, men far more often than women. The exact cause is unknown, but experts believe it's a combination of genetic and environmental factors.

Gao said that though the drug levodopa is the current standard treatment for Parkinson's, much more is needed. He is scheduled to present the findings in Toronto at the annual meeting of the American Academy of Neurology in April.

The findings came from an analysis of data on 136,474 people who did not have Parkinson's at the start of the study. In a six-year span, 293 were diagnosed with the disease. Those who took the largest doses of ibuprofen were less likely to have developed Parkinson's than were those who took smaller amounts of the drug, the study found.

No other pain reliever was found to lower the risk for Parkinson's.

Dr. Michele Tagliati, an associate professor of neurology and director of the Parkinson's Disease Center at the Mount Sinai School of Medicine in New York City, described the results as somewhat surprising and said they emphasized the need for further study.

"It's intriguing [that the finding applied to] just ibuprofen and not aspirin or acetaminophen or other commonly prescribed medications for inflammation because it implies something more specific to ibuprofen that should be investigated," Tagliati said. "So it narrows the focus to a subgroup of [anti-inflammatory drugs]."

Tagliati called the study "eye-opening." Parkinson's is not considered an inflammatory disease, he said, adding: "We might be missing something. There is more work to be done."

But in the meantime, Tagliati said, he would "definitely discuss ibuprofen use" with his patients because, if it works to protect against the disease, it could very well benefit those who already have it.

He cautioned that persistent use of ibuprofen can lead to gastritis, or inflammation of the stomach lining, but said that, in comparison, "there is very little to lose when measuring its side effects against the effects of Parkinson's," which can include loss of balance, stiffness, hallucinations and dementia.

18 February 2010

Happiness Wards Off Heart Disease

BBC News

Being happy and staying positive may help ward off heart disease, River Rogue Heart Doctors suggest.

US researchers monitored the health of 1,700 people over 10 years, finding the most anxious and depressed were at the highest risk of the disease.

They could not categorically prove happiness was protective, but said people should try to enjoy themselves.

But experts suggested the findings may be of limited use as an individual's approach to life was often ingrained.

At the start of the study, which was published in the European Heart Journal, participants were assessed for emotions ranging from hostility and anxiousness to joy, enthusiasm and contentment.

They were given a rating on a five-point scale to score their level of positive emotions.

By the end of the analysis, some 145 had developed heart disease - less than one in 10.

But for each rise in the happiness scale there was a 22% lower risk of developing heart disease.

A team of Trenton Cardiologists believes happier people may have better sleeping patterns, less liable to suffer stress and more able to move on from upsetting experiences - all of which can put physical strain on the body.

Lead researcher Dr Karina Davidson admitted more research was needed into the link, but said she would still recommend that people try to develop a more positive outlook.

She said all too often people just waited for their "two weeks of vacation to have fun" when instead they should seek enjoyment each day.

"If you enjoy reading novels, but never get around to it, commit to getting 15 minutes or so of reading in.

"If walking or listening to music improves you mood, get those activities in your schedule.

"Essentially spending a few minutes each day truly relaxed and enjoying yourself is certainly good for your mental health and may improve your physical health as well."

It is not the first study to suggest there is a link between happiness and ill health.

But Ellen Mason, of the British Heart Foundation, suggested such an association may be of limited value anyway.

"We know that improving your mood isn't always easy - so we don't know if it's possible to change our natural levels of positivity."

Romulus Cardiologists state that things like reducing cholesterol and diabetes are more important when it comes to reducing heart disease.

But at the end of the day, heart disease is still the biggest killer in the UK so anything you can do to help should not be ignored.

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15 February 2010

Blood Test May Predict Rheumatoid Arthritis


A simple blood test may allow doctors to identify a debilitating form of arthritis years before any symptoms appear, which may help to stop the disease in its tracks, new research suggests.

Rheumatoid arthritis (RA), which affects an estimated 1.3 million Americans, is an autoimmune disease that attacks the joints, causing inflammation, pain, swelling and stiff joints. Early diagnosis and treatment are key to preventing long-term joint damage, but the warning signs of rheumatoid arthritis are often easily confused with those of other diseases and conditions.

Now, a new study reports that markers of inflammation that can be detected in the bloodstream rise long before symptoms of the disease. This finding holds out the possibility that doctors can one day treat rheumatoid arthritis before it starts to take a toll on the patient. Treating rheumatoid arthritis early and aggressively with a combination of drugs provides the best odds of preventing joint damage.

The study "moves the whole field along," says rheumatologist Dr. Lionel Ivashkiv, M.D., an associate chief scientific officer at the Hospital for Special Surgery, in New York City. "In the future, in combination with other tests and risk factors--such as genetics, smoking, and family history--we can maybe predict who is at high risk for developing RA."

In the new study, which appears in the February issue of Arthritis & Rheumatism, researchers in Sweden analyzed the blood samples of 342 people, 86 of whom went on to develop rheumatoid arthritis up to five years after giving blood. Overall, the people who ultimately developed rheumatoid arthritis had higher levels of proteins and other substances involved in inflammation in their blood compared to those who didn't develop the disease.

Rheumatoid arthritis drugs target some of the inflammatory markers that were elevated, such as tumor necrosis factor (TNF).

When all 30 of the markers that the researchers measured are taken into account, the test would correctly predict 86 percent of the time the individuals who would ultimately require rheumatoid arthritis relief, according to the study.

"When a patient with RA comes in now, their immune system is on fire," says Dr. Richard Keating, M.D., a professor of rheumatology at the University of Chicago. "The researchers are working backwards and trying to figure out what started the fire. This will help unlock the pathway involved in how this disease occurs, and may open up new early treatment opportunities."

Dr. Eric Matteson, M.D., the chairman of the rheumatology department at the Mayo Clinic College of Medicine, in Rochester, Minnesota, calls the new findings "a step in the right direction," but says that it is premature to conclude that a blood test can predict who will develop rheumatoid arthritis with any degree of certainty.

Many of the inflammatory markers measured in the study are not specific to rheumatoid arthritis, Matteson points out. They reflect "general immune system activation," he explains, and could indicate a host of other inflammatory autoimmune diseases (such as lupus or psoriasis), or even a viral infection.

Still, he says, "It is exciting to think that...we could be alerted to the fact that [people] may go on to develop RA or another autoimmune disease."

Blood tests that accurately identify the warning signs could eventually help doctors tailor rheumatoid arthritis treatments to individual patients, Matteson adds. If researchers are able to pinpoint the blood markers of rheumatoid arthritis, doctors could use that information to assess the severity of individual cases and predict which medications are likely to be most effective for which patients, he says. (This approach is already used to treat other diseases, including some types of cancer.)

However, Ivashkiv stresses, the blood testing used in the study is not likely to be used by arthritis doctors in the near term. "It is another way of trying to identify patients with early RA, but it is not practical yet," he says.

California Questioning Legality of BCBS Rate Hikes

LA Times
The scheduled March 1 hike of up to 39% for individual health insurance policies will not take effect before May 1. In the meantime, California regulators will analyze the legality of the increases.

Reporting from Sacramento - Anthem Blue Cross on Saturday announced it would delay until May 1 controversial price increases of up to 39% for its individual health insurance policyholders in California, but maintained its rates were fair, legal and necessary.

The announcement followed a barrage of criticism in recent weeks from policyholders, consumer advocates, regulators, state legislators, members of Congress and the Obama administration.

State Insurance Commissioner Steve Poizner said Saturday that he secured an agreement with Anthem to postpone for at least two months the increases that had been set to take effect March 1 for many of the estimated 800,000 policyholders.

The delay, he said, would give state regulators time to have newly hired outside health-insurance actuarial experts analyze Anthem's rates to make sure they don't violate California law.

"We have instructed the actuaries to review the rates with a fine-tooth comb to ensure they comply with state law that requires that 70 cents of every dollar in premiums is spent on medical benefits," Poizner said. "Should they find that these rate increases were unwarranted, I will immediately take action to get Anthem Blue Cross to follow the law and lower their rates."

In Washington, Secretary of Health and Human Services Kathleen Sebelius said the agreement "underscores the urgency of passing real health insurance reform." She has been critical of the insurer's explanations of the rate hikes.

"While a two-month delay offers some temporary relief," she said, "what California families need is long-term health insurance security, so that they don't face sharply higher prices or fewer benefits."

Anthem is the largest for-profit insurer in California, and it is a unit of insurance giant WellPoint Inc. of Indianapolis.

Headquartered in Woodland Hills, Anthem said it welcomed the state's review and was confident that regulators would find its rates to be justified. The company blamed the increases on rising medical costs and an exodus of health consumers from its ranks caused by job loss and consumer belt-tightening.

WellPoint executive Brian Sassi, who oversees the company's individual policies nationwide, defended the increases in a statement. "Anthem filed these rates with the appropriate regulators in November of 2009," he said. "They are actuarially sound and in full compliance with all requirements in the law.

"Our decision to agree to postpone the rate adjustments does not change the underlying issue," the statement continued. "All health plans are in the same situation, trying to deal with the steadily increasing medical costs in the delivery system, which are not sustainable."

The proposed rate hike should average about 25%, and less than a quarter of the company's policyholders should see increases of 35% to 39%, the company said. Some customers can expect rate reductions, it added.

As public criticism of the rates grew, so did action by government officials. Anthem faces three inquiries over its rates, which followed what policyholders say were large increases last year.

In addition to the inquiry by state insurance regulators, Congress has opened an investigation, and a panel of the House Committee on Energy and Commerce has scheduled a hearing Feb. 24. The California Assembly's health committee will conduct a hearing Feb. 23.

Poizner said Saturday that he was doubtful of Anthem's position. Those kinds of jumps appear to be out of line "in the middle of a deep recession when people are struggling," he said.

And he said he has a "healthy skepticism" about Anthem's assertion that it spends at least 70% of its revenues from sales of individual health insurance policies on medical care for its customers.

Poizner said he has the legal authority to suspend Anthem's license to sell insurance in California if he finds that the company has violated state law.

California consumer advocacy groups also welcomed the two-month delay, but said they feared that state law doesn't give the commissioner enough authority to approve or disapprove changes in health insurance rates.

That may be why Poizner's office said little publicly when it first reviewed Anthem's rate increase filing last fall, said Anthony Wright, executive director of Health Access California, a statewide consumer healthcare coalition in Sacramento.

"It basically got rubber-stamped a couple of months ago," Wright said. "But after the spotlight came on, there was a reason to look further into the reasons for the rate increase."

Jerry Flanagan, health policy director at Consumer Watchdog in Santa Monica, said Anthem's efforts may prompt a backlash. He urged the Legislature to give Poizner more power to review and possibly disapprove new rates. "Existing law is inadequate to restrain rate increases," he said.

State lawmakers, led by Assemblyman Dave Jones (D-Sacramento), are pursuing bills that make health insurance just as highly regulated in California as automobile insurance. Proposition 103, an initiative approved by voters in 1988, requires that automobile insurers get approval from the insurance commissioner before they can raise or lower rates.

Jones, who is chairman of the Assembly health committee, said Proposition 103-type regulation is the only way to keep consumer health costs in check. Although such legislation failed in 2007 and 2009, Jones predicted that the outcome could be different this year because "the public tolerance for these outrageous rate hikes has been exhausted."

12 February 2010

Valentine's Science: Why Gauging Sexiness Is Sophisticated

National Geographic

This Valentine's Day, those meaningful looks cast at an attractive stranger may be signs of some of the most sophisticated thoughts a person can have.

That's the conclusion of recent brain scan studies, which are starting to reveal that deciding who we find attractive—even on a purely superficial level—is a much more complex process than an instinctual reaction.

For years neuroscientist Stephanie Ortigue of Syracuse University and Francesco Bianchi-Demicheli of Geneva University Psychiatric Center have been examining the brain's role in sexual experiences.

Most recently, the pair found that people making quick judgments about others' sexiness are using regions of the brain associated with higher functions, such as understanding the intentions of others and self-awareness.

In fact, higher brain regions seem to activate before they receive information from the visual cortex or the brain's emotional centers, Ortigue said.

Previous theories had suggested the brain first acquires information about sexual attractiveness from visual cues, which are then sent upward through the emotional centers and finally on to regions of more complex thought.

But Ortigue's study shows that the sophisticated mind may be first sending information downward, providing the visual cortex with a blueprint for who is attractive while prepping our emotional centers with prejudged responses.

"We've found the brain knows who we desire and when we desire before we are aware of it," she said. "It's very unconscious."

Self-Image Key to Attraction?

For their study, published in 2008 in the journal NeuroImage, Ortigue and Bianchi-Demicheli wired a group of 13 healthy adults so the scientists could record brain activity via a technique called high-density EEG neuroimaging.

The volunteers were asked to look at pictures of people in swimsuits and decide whether the subjects were hot or not. (Related: "Bikinis Make Men See Women as Objects, Scans Confirm.")

Most people made a decision in well under half a second, the study authors report. But during that short amount of time, several different regions of the brain lighted up electrical activity, including higher brain regions.

One of the areas most active in desire is intimately involved with people's self-awareness and self-image, the researchers found.

"Basically what that means is that people who have disorders of their self-image might also have disorders of sexual desire," Ortigue said.

In addition, test subjects took slightly longer to identify attractive people than they did to discount the unattractive—a finding that makes sense to evolutionary psychologist Donald Symons of the University of California, Santa Barbara.

"For a stimulus image to be highly attractive, all the observable attractiveness cues must fall into the highly desirable range," said Symons, who was not involved in the study. (Related: "Symmetrical Bodies Are More Beautiful to Humans.")

But just one unattractive quality, such as obesity or extreme acne, could be enough of a turnoff for someone to instantly judge a person as undesirable, he said.

"So detecting ugliness would be, on average, an easier perceptual problem, and one that could be made more quickly then detecting great beauty."

Evolution of Desire

Ultimately, Ortigue and Bianchi-Demicheli's research could provide new insight into why humans have evolved to desire others the way we do.

"What I would expect, and what Stephanie has begun to demonstrate, is that complex, specialized cortical adaptations exist that were designed to solve the problem of mate choice faced by our ancestors," Symons said.

In other words, the brain's current wiring could be a product of the way ancient humans gathered information about a potential mate's value based on specific physical characteristics.

In the days before Proactiv and Oil of Olay, for example, skin condition might have been a good indicator of a person's age or larger health problems.

"Therefore," Symons said, "we'd expect natural selection to have created psychological mechanisms specialized to detect and use reliable information about mate value."

For future work, study author Ortigue said she would like to move beyond photographs and wire live couples to record their mutual brain activity, allowing her to map the dynamics of desire "in the flesh."

11 February 2010

Big Changes Coming to DSM-V, the Psychiatrist's Bible

ABC News
New Diagnostic and Statistical Manual of Mental Disorders Makes Changes to Eating and Gambling Disorders But Leaves Sex Alone

Substantial changes are in the offing for the "psychiatrist's bible," the Diagnostic and Statistical Manual of Mental Disorders, according to a draft of the forthcoming fifth edition.

The American Psychiatric Association (APA) posted the draft of DSM-V on a special Web site, www.dsm5.org, to obtain comment from its members, other members of the mental health community, and the public.

At a telephone press briefing prior to the draft's release, members of the APA team leading the DSM revision highlighted several substantial innovations they are proposing:

* Re-categorizing learning disorders, including creation of a single diagnostic category for autism and other socialization disorders, and replacing the controversial term "mental retardation" with "intellectual disability"

* Eliminating "substance abuse" and "substance dependence" as disorders, to be replaced with a single "addiction and related disorders" category

* Creating a "behavioral addictions" category that will include addictions to gambling but not to the Internet or sex

* Offering a new assessment tool for suicide risk

* Including a category of "risk syndromes" for psychosis and cognitive impairment that are intended to capture mild versions of these conditions that do not always progress to full-blown psychotic disorders or dementia, but often do

* Adding a new disorder in children, "temper dysregulation with dysphoria," for persistent negative mood with bursts of rage

* Revising criteria for some eating disorders, including creation of a separate "binge eating disorder" distinct from bulimia

* Using "dimensional assessments" to account for severity of symptoms, especially those that appear in multiple diagnostic categories

The APA will accept comments through April 20. The work groups managing the revision will consider them and make further changes as needed to the draft, said Dr. David Kupfer, of the University of Pittsburgh and chairman of the DSM-V task force.

The draft diagnostic criteria will then undergo two years of field testing. The final DSM-V is scheduled for release in May 2013, a year later than originally planned.

In the area of neurodevelopmental disorders, DSM-V will put dyslexia and dyscalculia -- reflecting disabilities of reading and mathematics, respectively -- into a new category of learning disabilities.

Autism, Asperger's syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified will make up the new "autism and related disorders" category.

The head of the APA's work group on substance-related disorders, Dr. Charles O'Brien, of the University of Pennsylvania, told reporters on the press call that substance dependence and abuse had no basis in the research on addictions.

"We unanimously agreed that… there really isn't evidence for an intermediate stage [short of addiction] that is now known as abuse," he said. Instead, there will be substance use disorders for each of the major types of drugs that cause problems, such as alcohol.

He added that the term "dependence" was problematic as a psychiatric diagnosis because some types of physical dependence are "completely normal" for some medications, such as opioid painkillers.

In fact, under the draft the DSM-V will include "discontinuation syndromes" to allow physicians to properly assess symptoms of withdrawal from psychoactive substances which include caffeine, O'Brien said.
He also said his work group had considered including sex and Internet addictions as disorders, but decided there was insufficient evidence to develop reliable diagnostic criteria for them. Consequently, gambling addiction is slated to be the only disorder formally listed in the behavioral addictions category.

But O'Brien added that under current plans, sex and Internet addiction would be included in an appendix to DSM-V, intended to encourage additional research that could lead to their inclusion in future editions.

APA leaders also emphasized the two new suicide risk assessment scales planned for DSM-V, one for adolescents and one for adults.

Dr. David Shaffer, of Columbia University, told reporters on the press call that suicide nearly always occurs in the context of some psychiatric disorder, but not always depression.

The new risk assessment tools focus on risk factors such as impulsive behavior, heavy drinking, and chronic severe pain and illness.

In DSM-IV, suicidal ideation is treated as a symptom of major depression and certain other disorders.

Shaffer also explained the genesis of the proposed new childhood disorder, temper dysregulation with dysphoria (TDD).

"About 40 percent to 60 percent of the cases [seen by child psychiatrists] will be children who are doing things that other people don't want them to do," he said. Many of these are children who are "stubborn and resistant and disobedient and moody."

There is currently a recognized syndrome known as oppositional defiant disorder, but some children also display severe aggression and negative moods that go beyond mere stubbornness, according to Shaffer.

Such children are often tagged as having juvenile bipolar disorder, but research has shown that the label is often inappropriate, since they usually do not qualify for a bipolar disorder diagnosis when they reach adulthood, though they remain dysfunctional. More often, these children are diagnosed as depressed when they become adults.

He said the addition of TDD would better describe the severity and frequency of irritable behavior while also recognizing the mood disorder that goes with it.

Another innovation in DSM-V will be the extensive use of so-called dimensional assessments. Whereas DSM-IV relied heavily on present-absent symptom checklists, the new edition will include severity scales for symptoms such as anxiety or insomnia that may appear to larger or smaller degrees in many different mental illnesses.

Dr. Darrel Regier, the APA's research director, said such checklists "don't always fit the reality that someone with a mental disorder experiences." Often, a symptom like insomnia isn't on the checklist for a particular disorder, he said, "but they can still affect patients' lives and affect the treatment planning."

Incorporating quantitative dimensional assessments should allow clinicians to develop treatment and response-monitoring plans better tailored to individual patients' needs, Regier said.

A closely watched issue in the DSM-V revision has been whether to change or do away with gender identity disorder, now listed in DSM-IV. At this point, the draft retains the designation but with some changes, officials said.

People who consider themselves "transgendered" have long criticized DSM-IV and previous editions for labeling them with a mental disease when their problems, they believe, are purely somatic -- that is, they have the wrong genitalia and hormonal balance.

At the APA's annual meeting last May, members of the transgender community made a case for dropping gender identity disorder from DSM-V, but keeping some kind of "gender variance" diagnosis as a medical condition. Such an approach would eliminate the stigma of a psychiatric diagnosis while leaving a pathway for third-party (insurance) payment for gender transition treatments, they said.

Dr. William Narrow, the APA's research director for DSM-V, told reporters that the draft does remove the term "disorder" from the condition when applied to children, renaming it as "gender incongruence."

For adults, gender identity disorder will remain in DSM-V but with substantially altered diagnostic criteria, Narrow said.

But APA officials said the organization planned more discussions with members of the transgender community.

Kupfer, the DSM-V task force chairman, stressed that further changes in many diagnostic categories are likely following the comment period and field trials. Final revisions will be submitted in 2012 for approval by the APA's two governing bodies, the Assembly and the board of trustees.

10 February 2010

The New Face of Sleep

The Wall Street Journal
As Patients Balk at Bulky Masks, New Efforts to Treat Sleep Apnea

For the 18 million people with obstructive sleep apnea, the remedy is far from perfect: bulky and expensive masks that some compare to sleeping in scuba gear.

As the number of people with sleep apnea is expected to rise, doctors and medical device makers are trying new treatments. New masks, while still bulky, aim to be more comfortable. Dentists have begun prescribing an appliance that draws the lower jaw forward to create more space in the airway. Some doctors recommend several types of surgery. And some try basic lifestyle changes, like sleeping in a different position. For patients who don't find relief from any of these, there's an odd recommendation: Learn to play the didgeridoo (more about that later).

Patients with sleep apnea stop breathing during sleep because the soft palate collapses and blocks the upper airway. A tell-tale symptom is chronic and loud snoring. The most common and effective treatment is "continuous positive airway pressure," or CPAP. The treatment involves wearing a breathing mask to sleep—which some people find impossible to do. As few as 50% of people who are prescribed a CPAP device actually use it regularly.

Aging and obesity both can contribute to sleep apnea; research suggests the number of people with the condition will grow, as the population ages. Some experts believe that lack of awareness among some patients and doctors has led to underdiagnosis and that the number of patients actually is closer to 30 million.

The most common symptom is snoring; daytime sleepiness is another sign. Sleep apnea heightens a patient's risk of hypertension, diabetes and heart attacks, because it heightens carbon-dioxide levels in the blood stream and stresses the cardiovascular system. Last fall, the National Transportation Safety Board recommended that drivers and pilots of commercial buses, trucks, airplanes and ships be screened for the condition, citing several accidents in which undiagnosed sleep apnea was thought to play a role.

A variety of specialists, including pulmonologists, ear, nose and throat doctors, neurologists, surgeons and dentists, treat sleep apnea. The most accurate diagnoses are performed in a sleep lab, where the patient goes to sleep overnight while being monitored. The cost, about $1,000, is usually covered by insurance with a doctor's prescription. Sleep apnea is measured on an apnea-hypopnea index, combining the number of apneas, or pauses in breathing, with hypnopneas, or instances of excessively shallow breathing, in an hour. An index of 1 to 15 is considered mild, 16 to 30 is moderate, and over 30 is considered severe. Typically, patients are diagnosed with sleep apnea only if they stop breathing five or more times in an hour.

First mentioned in medical literature in the 1960s, sleep apnea was at first treated with a tracheotomy, a breathing tube inserted into a surgical incision in the windpipe—a treatment that was worse than the disease. Today, 60% to 70% of patients are treated with CPAP, in which the breathing mask, connected by tube to an air pump, sends pressurized air through the patient's nose. The air flow keeps the upper airway open and prevents apneas.

A 2005 study in the Lancet found sleep apnea patients treated with CPAP had cardiovascular mortality rates similar to healthy individuals. A 2006 analysis in the journal Sleep concluded that CPAP reduced apnea incidents and improved sleep, but that its impact on cardiovascular risk was mixed.

A patient is supposed to wear the mask while sleeping for eight hours a night for the rest of their life. Usually covered by insurance, the device costs from $500 to $4,000.

Some patients experience dramatic relief. Denise Poole, a 56-year-old former manager of a call center who lives in Jeannette, Pa., spent years being exhausted during the day but unable to sleep more than a few hours at night. She was so restless that her husband started sleeping in a separate room. Thinking she was clinically depressed, Ms. Poole went to see her doctor, who prescribed antidepressants.

But that only made sleep more difficult. Cutting caffeine and late-night snacks didn't work, either. Finally, Ms. Poole ended up at a sleep lab, where tests showed she was stopping breathing 47 times an hour while asleep. She was diagnosed with obstructive sleep apnea and prescribed a CPAP device. Within days of using it, she felt a return of energy. "It was like someone turned the light back on in my life," Ms. Poole says.

Still, many patients complain that the CPAP mask and the air pressure make them feel claustrophobic. Others balk at sleeping with a mask and tubes on. "It took me three years to look in the mirror with my mask on," Ms. Poole says. CPAP success is measured by a reduction in the apnea-hypopnea index, or by measures such as a standardized sleepiness scale.

CPAP device makers—including Philips Respironics, a Pittsburgh unit of Philips Electronics NV, and ResMed Inc., of San Diego—have introduced improvements to the device. Some have built-in humidifiers to keep air moist, and some can have their airflow adjusted to individual patients' needs, making breathing more comfortable. Newer models tend to be smaller and quieter. Makers also are incorporating softer materials into the masks and offering a range of options such as full-face masks (good for people with facial hair, who may have a tough time getting a good seal) and masks that cover only the nose.

CPAP device makers see a bonanza in the U.S. Mike Matson, senior medical device analyst with Wells Fargo Securities, estimates the CPAP market was $2.3 billion globally last year, with 60% of it in the U.S. He is forecasting 12% growth in the U.S. for 2010. "There's a lot of people who have [sleep apnea] and haven't been diagnosed yet," Mr. Matson says. Respironics and ResMed currently control about 80% of the U.S. market.

Sleep-apnea dental appliances, costing from $2,500 and $3,000, are often recommended for patients who can't tolerate the CPAP treatment; there are some indications that compliance with these appliances is higher. But there is a significant downside. They can cause a patient's teeth to move, and the patient risks developing a painful case of temporomandibular jaw syndrome, or TMJ.

When he started waking in the middle of the night choking, Dave Morton, a 35-year-old co-president of an online car-rental company in New York, sought help. At a sleep lab, he was diagnosed with sleep apnea, and his doctor prescribed a CPAP machine. But exhaling against the device's airflow made him feel disoriented, and he often threw the mask off in his sleep. (Sinus problems may have contributed to his difficulties, he says.) "I was very stressed and couldn't sleep," Mr. Morton recalls. "I never woke up feeling refreshed."

After two years of on-and-off CPAP use, Mr. Morton switched to a dental appliance. He was tested in a sleep lab with the appliance, and his apnea score dropped sharply. "I'm happier and healthier," he said. "I can tell my brain is working better again."

Surgery is an extreme option, often recommended for people with complicating issues such as a deviated nasal septum, nasal polyps or enlarged tonsils. Some interventions involve actually surgically advancing the lower jaw—which can cost as much as $50,000 and require weeks of recovery. Less-invasive surgical treatments are becoming more common. Some involve removing soft tissue from the back of the throat and palate; in somnoplasty, radiofrequency energy is used to shrink tissue in the nasal passage. Other procedures create more space in the airway by shifting how the tongue is attached. Injection snoreplasty involves injecting a chemical into the soft palate to create scar tissue, which reduces snoring.

Simple lifestyle changes can add to the benefits of other treatments. Sleeping while lying on the side, instead of the back, can prevent the airway from closing, some studies show. Losing weight can help, and so can stopping smoking, since smoking leads to inflammation and fluid retention in the airway. Sufferers also should avoid alcohol and sedatives, which can further relax the airway during sleep.

If all else fails, there is always the didgeridoo, an indigenous Australian musical instrument. In a study published in the British Medical Journal, 25 patients with sleep apnea who practiced playing it for about 30 minutes a day, six days a week for four months, significantly reduced the number of apneas they had during sleep; daytime sleepiness also decreased. Scientist believe the breathing technique required to play the didgeridoo strengthens the upper airway and makes it less likely to collapse.

08 February 2010

Study Finds Mental Benefit of Fish Oil

The Wall Street Journal

Fish oil pills may be able to spare some young people with signs of mental illness from a progression into fully developed schizophrenia, according to a preliminary study of 81 patients in Austria.

The study adds to evidence suggesting that severe mental illness may be prevented with intervention. The researchers are starting a larger study in eight cities, hoping to replicate the findings, which appear in the February issue of Archives of General Psychiatry, released Monday.

A severe mental illness, schizophrenia affects adolescents and young adults. Some 2.4 million Americans have the disorder, which is treated with antipsychotic medication.

"Schizophrenia is among the most mysterious and costliest diseases in terms of human suffering, so anything that gives some hope to avoid this is great,'' said lead author Dr. G. Paul Amminger, formerly in Vienna and now at the Orygen Youth Health Research Center at the University of Melbourne in Australia.

Researchers have wondered if the disease could be stopped before it overpowers a person's grip on reality. Studies have tried antipsychotics in select young people, but side effects pose ethical questions, and results have been mixed.

Researchers in the new study identified 81 people, ages 13 to 25, with warning signs of psychosis, including sleeping much more or less than usual, growing suspicious of others, believing someone is putting thoughts in their head or believing they have magical powers. Forty-one were randomly assigned to take four fish oil pills a day for three months. The other patients took dummy pills.

After a year of monitoring, 2 of the 41 patients in the fish oil group, or about 5%, had become psychotic, or completely out of touch with reality. In the placebo group, 11 of 40 became psychotic, about 28%.

No one knows what causes schizophrenia but one hypothesis is that people with the disease don't process fatty acids correctly, leading to damaged brain cells. Omega-3 fatty acids in fish oil could help brain cells repair and stabilize, the researchers speculate.

Dr. Janet Wozniak of Harvard Medical School said the findings might reasonably cause psychiatrists to recommend fish oil to some patients because there are known benefits and little risk.

Care Providers Look to Montessori Techniques for Treating Dementia

Public News Service

LANSING, Mich. - Elder care providers across Michigan and the nation are turning to more-specialized and individualized care for dementia patients, based on methods used in Montessori pre-schools to maintain cognitive ability. Meanwhile, families caring for elders at home are losing state resources.

Deedre Vriesman is a program manager for The Woods at Maple Creek, a non-profit, live-in facility run by Lutheran Social Services. She says the mantra for dementia care used to be "clean, safe and dry," but one of the latest techniques includes the learning approach used with pre-schoolers.

"It's the same methods that you use for children who are in Montessori-based schools; very hands on, sorting tasks, feeding tasks, smelling different things, using reminiscence. That's all built in to make it a meaningful event that makes sense to the person, so it's more familiar."

The high price of elder care facilities forces many families to keep a loved one at home for a much longer time, says Vriesman. Before cuts to funding, those families could count on help from the state to find resources, she adds.

"They had a program called the Single Point of Entry. A family member could call and say 'my grandma needs a placement, here's the type of things that I'm seeing with her.' Then, they could help you sort through, 'okay, based on that, these are the programs that could help.' Because, it is overwhelming."

More than 180,000 Michigan senior citizens are diagnosed with dementia. That represents a six-percent increase in the last decade. Vriesman says state money is no longer available to help families find resources for dementia patients, and the drugs to treat dementia are often expensive with limited results. Advocates say the most effective treatment focuses on maintaining cognitive ability and life enrichment using the skills a patient has retained.

Interview with WellPoint's CEO: 'A Wasted Opportunity'

Wall Street Journal
New York -- Angela Braly is in good spirits considering that her company seems to have narrowly avoided being converted into a public utility, if not destroyed outright. One gets the sense that she's always in good spirits. After years of sustained political assault, the power of positive thinking probably helps.

Mrs. Braly is the CEO and president of WellPoint, the largest U.S. commercial health insurer by membership. Her company's affiliated health plans in 14 states cover 34 million people—or roughly one out of nine Americans. It contracts with 82% of the nation's primary-care physicians, 84% of specialists, and 94% of hospitals. That scale lands her on the most-wanted list in President Obama's Washington, though it's tough to imagine a less likely villain than the very Midwestern Mrs. Braly.

"It's just not clear where we go from here," says the highest ranking woman in the Fortune 500, sounding as astonished as anyone about Scott Brown's victory. Merely days before this interview in WellPoint's lower Manhattan offices at the edge of Ground Zero, Massachusetts voters effectively sent ObamaCare to its own death panel. The reflexive liberal response was to castigate the likes of Mrs. Braly. "I mean, to be fair, the status quo is working for the insurance industry, but it's not working for the American people," Mr. Obama said recently.

To actually be fair, the insurance industry was a cheerleader for the plan, at least until the policy substance congealed sometime in September. "Obviously, we've been involved in this discussion for a while—more than a year—and if you think about it we came to the table early, early on and said we're going to be advocates for responsible, sustainable health-care reform done right," Mrs. Braly says. "We really do have to get at the underlying question of health-care costs."

That was the core promise of ObamaCare. Overall health costs for people insured by WellPoint increased by 8.9% in 2009 alone, and arresting this climb was the reason so many industry groups, not only the insurers, joined with the White House and Democrats. Nobody thinks the status quo is a success. But as Mrs. Braly notes ruefully, "The nature of health care is very complex, and sometimes the nature of politics is very simple."

The tragedy, as she sees it, is what "a wasted opportunity" it all turned out to be. "Health-care reform" soon became "health-insurance reform" exclusively. "It was a pivot that was—unfortunate," she says, "because it is not going to solve the longer-term problem."

It's hard to see how WellPoint could be to blame for surging health spending, Mrs. Braly says, when 85 cents out of every premium dollar or more "is paid out in the actual cost of care, doctors, hospitals, suppliers, drugs, devices." Confiscating the 2009 profits of the entire insurance industry would pay for two days of U.S. health care.

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ObamaCare would have standardized benefits and then severed the connection between the prices insurers are allowed to charge and the true costs of health care. Insurers would have to offer coverage to anyone who applied regardless of health risks or pre-existing conditions—a rule that is known as "guaranteed issue"—and would not be allowed to vary premiums among customers except within very limited bands. Everyone would then be compelled to purchase health insurance coverage.

Mrs. Braly still believes insurers "could make [this system] work from an affordability point of view," but only if these rules are realistically designed and there is "a meaningful requirement that people join in the pool." She argues that the bill Congress was on the brink of passing would merely have ensured higher insurance costs.

"People won't buy insurance until they're sick," she explains. "If you can call on your way to the hospital and get coverage, it's not really insurance at that point." Thus "prices go up and the number of covered people goes down."

Such destruction wouldn't even qualify as an unintended consequence, considering that state governments have plenty of experience blowing up the insurance markets. "Look at New York," Mrs. Braly says. "Look at Maine. Look at what's going on in Massachusetts right now. Look at what happened in the '90s in Kentucky."

Take those states in turn. "In Maine, where guaranteed issue went into effect in 1993, there were 11 insurance carriers in the individual market, and now there are two: Us, and another company that would not be called in any circle an equivalent health insurance company." In Kentucky, 45 insurers fled the state, with WellPoint the last one standing, until the state started in 1998 to repeal most of these regulations.

Depending on the plan, WellPoint's monthly premium for a 20-year-old in Indianapolis, where the company is based, ranges from $53 to $202. But the same young adult looking for similar coverage in Albany would face costs anywhere between $832 and $1,047. Obviously health insurance costs vary across the country, Mrs. Braly says, but these disparities are almost entirely due to New York health insurance regulatory mandates. In a state with 19 million people, 88 New Yorkers between the ages of 18 and 24—88!—have bought WellPoint's best-selling individual insurance product because insurance laws make it perfectly rational not to acquire costly coverage until people need it.

This scheme would have been, and might still be, imposed on the rest of the country. At the request of several congressmen last year, including some Democrats, WellPoint mined its own actuarial data to model ObamaCare and found that it would as much as triple premiums for the small businesses and individuals who are most of the company's customers. The White House political shop promptly compared WellPoint to a tobacco company.

But wasn't this fracas predictable? In other words, given the state regulatory experience, not to mention the ideological inclinations of the Democratic Party, was it really politically wise for the industry to embrace ObamaCare?

Mrs. Braly concedes that it was "a risky move, but our decision, and I think it was the right one, and it was a bold one, was to ask how can we best serve our customers. Can we lower health insurance prices for our customers, can they get better service and better value? The answer is: Yes. . . ."

"We've been a heavily regulated industry for as long as I've been part of health care," she continues. Frankly, health care and politics are "inextricably intertwined." Mrs. Braly notes, too, that the government on its own is largely incapable of "navigating through the health-care system, coordinating the very uncoordinated parts of the health-care system." In fact, hired WellPoint to run some $97 billion in traditional fee-for-service benefits in 2008, or more than a fifth of the program's total budget that year.

Mrs. Braly concedes that some people with pre-existing conditions can find it difficult to find affordable coverage, especially if they lose their job, get divorced, move, etc. "It's when people have no option that we're really in trouble and need to find a solution," she says. But a better alternative to central insurance planning is public-private partnerships to create insurance pools for those with high risks. "That was a great idea that got pushed aside, and I think we need to revisit that concept."

Mrs. Braly suggests that the industry gambled politically in part because the cost problem seems so insoluble, and that the hand of the industry was forced because the market clout of doctors and hospitals is making it increasingly difficult to contain health costs. "Is there competition in the underlying delivery system," she asks, "and is that lack of competition potentially driving up costs? . . . People have been talking about competition among insurers, and what they really need to be talking about is competition in the delivery of health care as well."

Realistically, it's not as if there's a market that sets health prices. Instead, they're negotiated between providers and health plans. Perhaps the doctors and hospitals who were largely exempted from the tepid cost-control provisions in ObamaCare shouldn't have been.

"We know there's a lot of redundancy, a lot of waste," she says. "If we have a contentious discussion with a major hospital system that people want to have access to," Mrs. Braly explains, and WellPoint doesn't meet its asking price, "then the question is what do you do about that access?"

"Hospitals come in and ask for major increases," she says. "They come in and say, you know, we need a 40% increase. It would blow your mind, the difference we start with in some of these negotiations. . . . Why does that procedure cost $10,000 in this place and down the street it costs $1,000—and when the hospital that's getting paid $10,000 is asking for a 40% rate increase, you have to say, why?"

As Mrs. Braly diagnoses the U.S. health-care system, its two main strengths are (a) choice and flexibility and (b) cutting-edge treatments and procedures. But while American medicine has been shaped by specialization, scientific advancements and major technological breakthroughs, it is paradoxically antiquated. The modern managerial and corporate practices for obtaining better productivity and quality that have revolutionized every other sector of the economy have largely passed over medicine. "Remember, for the most part, for providers of health care, it's a cottage industry," she says.

The reason costs are rising so fast, Mrs. Braly says, is because the way the health-care market is structured doesn't give providers reason to control costs. The solution is to "reintroduce the consumer to the health-care equation," and on that front, she believes, insurers "are actually the part of the health-care delivery system that is there to create the value."

Mrs. Braly thinks patients will make more cost-conscious decisions if they have the incentives and the tools—namely, the information about cost and quality that is the basis of any ordinary market. "Data just sitting there is not helpful, and its got to be meaningful, provided to the doctor and the patient in a meaningful way," she says. Far from simply being a bill-paying outfit or a hedge against risk, she sees WellPoint's fundamental role as making "the health dollar more valuable, less wasteful, more efficient."

WellPoint is an industry leader in data analytics; Mrs. Braly uses the example of knee surgery: Before the procedure, the company tells the patient which hospitals perform the most surgeries, which ones have the best medical outcomes, and where the costs are lowest. Ultimately this sort of prudent purchasing is the only durable way to lower health spending.

The White House had a different agenda, and Mrs. Braly says the controversy over ObamaCare should come as no surprise. "This is the most personal thing you can deal with. . . . Not only do we come to it and say we need the right solution, the right process, the right information, the right business model, but this is about my life," she says. "It's about what we value as people."

Mr. Rago is a senior editorial page writer at The Wall Street Journal.