Foreign Doctors—A Question of Equity

Consider these two facts:

• Close to 25 percent of U.S. doctors are foreign-born.
• Each year, developing nations spend $500 million to educate health care workers who leave to work in North America, Western Europe and South Asia.  As the most recent issue of the Journal of the American Medical Association (October 24-31) puts it:  “developing nations are subsidizing healthcare in wealthier nations.”

According to JAMA, “These unchecked flows of health workers leave regions with the greatest health care needs with the fewest workers .  .  . 37% of the world’s health care workers live in the Americas, predominantly in the United States and Canada, yet these countries carry only 10% of the global disease burden. In contrast, Africa is home to only 3% of the world’s healthcare workers, yet it has 24% of the global burden of disease.”

On the other hand, according to the American Medical Association, some 35 million Americans live in areas where there are not enough doctors. Nationwide, primary care doctors are in short supply, in large part because they are paid so much less than specialists. Medical students who know that they will graduate with tens of thousands of dollars in loans say that they don’t feel that they can afford to become internists or family doctors.

Moreover, the Kaiser Family Foundation reports that “the nationwide physician shortage is affecting rural and inner-city residents the most,” and following 9/11, “restrictions put in place on foreign doctors who want to practice in the U.S.” have made the situation worse.

Patients Managing Chronic Diseases: Not Your Average Consumer

In his new book, Health Care Reform Now!, Kaiser Permanente President George Halverson points out that when you look at the 10 percent of patients running up 70 percent of the U.S. health care bill, you find that most are suffering from one of five chronic diseases: diabetes, congestive heart failure, coronary artery disease, asthma and depression.

These diseases can be expensive because if they are not monitored properly, they can quickly lead to avoidable hospitalizations—and, in the case of diabetes, avoidable amputations.  One of the most pressing questions health care reformers face today is this: How can we better manage these very expensive diseases—and how can the patient participate in self-management?

Recently, Maggie handed me a Bulletin on Aging and Health from the National Bureau of Economic Research, which includes a synopsis of a paper (penned by James P. Smith of the RAND Corporation) which focuses on one of these chronic diseases—diabetes. Smith’s goal is to explore the relationship among diabetes, socioeconomic status, and the patient’s ability to self-manage treatment.

Of particular interest is Smith’s emphasis on education—which, he concludes, is a major factor in determining first, whether a patient is likely to suffer from diabetes, and secondly whether he or she can successfully self-manage. It’s this second point that I want to address, in part because it provides a good example of how a consumer-based approach to medicine distorts the complexities of health care. 

Hospitals & Nurses: Behind the Scenes

Recently I’ve begun reading allnurses.com, a website that offers an eye-opening window on conditions in U.S. hospitals.  (I found the site when allnurses reprinted my post about the nursing shortage).

Clearly nurses and doctors know more than virtually anyone else about what is going on in our hospitals, but they also realize that they risk reprisals if they speak out. When I was writing Money-Driven Medicine, I was surprised by how many physicians returned my phone calls. The great majority did not know me; I expected responses from perhaps 20 percent. Instead four out of five called back. To a man and a woman, they were most passionate about what many saw as the declining quality of healthcare. “We want someone to know what is going on,” explained one prominent Manhattan physician as he described how much care had deteriorated in many of New York City’s major hospitals. “But please don’t use my name,” he added. “You have to promise me that. In this business, the politics are so rough--it would be the end of my career.”

Nurses are in an even more vulnerable position. I could not find any who were willing to be interviewed. I e-mailed quite a few, promising anonymity, but not one responded.

On allnurses.com, however, nurses speak freely, knowing that their identities are protected and that their audience is composed of other nurses.  Here is what I have learned from some of the polls and forums on the site:

Shared Decision Making

In my last post, I talked about the uncertainties of medicine, and suggested that the relationship between doctor and patient must be built on trust.  (See “A Transaction Based On Trust”). I argued that this is why the consumer-driven model of medicine doesn’t work. It assumes that the doctor is a retailer selling his services and that as his customer the consumer must demand the best quality care at the lowest price. Immediately the relationship between buyer and seller begins to sound adversarial, just as it is in the commercial marketplace where “caveat emptor” always applies. 

But the health care market is not like other market places, and the doctor is not a retailer. He or she is a professional who has taken a pledge to put the patient’s interests ahead of his own interests.  For the transaction to go forward, the patient has to believe this. Who would go under the knife, or submit to any painful or invasive procedure if he didn’t trust the doctor? 

At the end of that post, I asked, “But what about the uncertainty of medicine. Does this mean that the patient must simply trust that his doctor has “the right answer?”

Not at all. The relationship between patient and doctor must be based on mutual trust. Just as the patient trusts the doctor to act as a professional, the doctor needs to trust the patient enough to be open with him about the uncertainties of the patient’s condition and the pros and cons of the treatments that they are considering.

Sometimes—but not always—the doctor must tell the patient: “In this particular case I can’t be sure what the best treatment would be. But here are the options and here are the risks and benefits of each.”    

Disease Mongering By Way of Restless Legs

Yesterday during lunch I saw an ad for Mirapex, a “prescription medicine used in the treatment of moderate to severe primary restless legs syndrome (RLS).” The fact that there was such thing as a restless leg syndrome seemed odd to me, so I did some sleuthing. (Maggie, who has in fact discussed RLS over at the Health Care Blog, has some great thoughts on the issue as well.)

 RLS is a “medical condition that is described as an urge to move the legs”—simple enough. The Mirapex website offers a list of question designed to help you diagnose yourself:

• Do you feel a strong desire to move your legs from time to time, often when they make you uncomfortable?
• Do those sensations in your legs occur or get stronger when you are inactive?
• Does moving around or stretching help ease those uncomfortable sensations in your legs?
• Do those uncomfortable sensations feel their worst at night?

Boehringer Ingelheim Pharmaceuticals, the manufacturer of Mirapex, is considerate enough to translate these symptoms into layman’s terms:

People often use words like "burning," "creeping," "crawling," "aching," "tingling," and/or "tugging" to try and describe their symptoms. Many people with restless legs syndrome have difficulty explaining the odd sensations they feel, even when talking to their doctor.

So far it seems that I may have RLS if my (1) legs get uncomfortable after sitting for a while and (2) I have trouble articulating this sensation. By these criteria, most anyone who has uttered the phrase “my leg feels weird” qualifies as an RLS sufferer.

A Transaction Based on Trust

The consumer of health care is unlike any other consumer, and the product he purchases is unlike any other product. This is something that those who embrace “consumer-driven medicine” choose to ignore.

Advocates like Harvard Business Professor Regina Herzlinger insist that if we just
put the consumer in the driver’s seat, giving him both  transparent pricing and a little “skin in the game,” the consumer  could put a lid on health care prices while demanding the best quality care.  Herzlinger is particularly hopeful that the baby-boomers, a group she describes as “the most manipulative, the most narcissistic and the most effective generation this country has ever seen,” can do the job. (Why one would want such a group setting priorities for our health care is beyond my understanding; I’ll return to this point in a later post.)

Last week I spoke at the Massachusetts’ Medical Society’s Leadership Forum on the rising cost of care.  In two earlier posts (here and here) I’ve described what other speakers had to say about how and why Massachusetts is running into trouble trying to fund its experiment in universal care.

In my speech, I explained why I don’t think that “consumer-driven medicine” is the answer. I don’t believe the “consumer” can rein in healthcare spending.  As an alternative, I proposed a “patient-centered” model of health care which depends on patient and doctor, working together.

Begin with the flaws in the consumer-driven model. First, it assumes that the patient has the same power that a buyer has in the commercial marketplace. But in truth, the patient does not have nearly as much leverage as other consumers.

Reminder: Comments Now Open!

You can comment on posts in Health Beat by Maggie Mahar directly by clicking on the "Comments" link below the introduction portion of each post. Please do join the discussion when something interests you--we'lll be responding.

The Dangers of a "Zagat Guide" to Physicians

Yesterday WellPoint announced that as of early 2008, a “new online tool” “will allow consumers to share their physician experiences with others” a la Zagat surveys. Zagat in fact is partnering with WellPoint on this initiative, and the format of ratings will be similar to other Zagat products, where customer anecdotes accompany ratings of different criteria on a 30 point scale. The rated criteria for doctors will be trust, communication, availability, and environment. Measurements of quality of care and health outcomes are not included in this rating system, an omission that Jane Sarasohn-Kahn points out over at HealthPopuli.

Jane is kinder toward this announcement than I am. Neglecting crucial information about quality misses the point about medicine—that it is devoted to improving health. As Jerry Flanagan of the Foundation for Taxpayer and Consumer Rights told USA Today yesterday, “the fact that a doctor might have a friendly administrator at the front desk is meaningless if they have a high medical-error rate.” It’s a bit like having car ratings only address color scheme and seat comfort: these are nice facts to know, but at the end of the day you want a car that you can rely on, a consistent performer that does its job and does it well.

Universal Coverage –Why Massachusetts is the Last Place to Begin the Experiment

At the Massachusetts Medical Society’s 8th Annual Leadership Forum last Wednesday, Dr. Steven Schroeder, former head of the Robert Wood Johnson Foundation and Distinguished Professor of Health and Health Care at the University of California, San Francisco, told a provocative story about a poll that asked patients in the U.S. `Canada,  Australia, New Zealand and the U.K the following question:

“If your personal doctor told you that you had an incurable and fatal disease, would you accept that diagnosis or seek a second opinion?

• In the U.S.           91 percent of patients said they would seek a second opinion.
• In Canada            80 percent                    “        “       “       “     “     “           “ 
• In Australia          71 percent                  “        “   
• In New Zealand     51 percent
• In the U.K.           28 percent 

“You have to love the British,” Schroeder commented. “You can just hear an Englishman saying ‘Well, Luv, it’s been a good life, hasn’t it? Now let’s make a pot of tea and discuss the funeral arrangements.”

At the other end of the spectrum, we find the Americans who, Schroeder noted, “are the only people in the world who expect to live ‘in perpetuity’.”

Today, I would like to suggest that our expectations as patients help to explain why we spend roughly twice as much per person on health care as most developed countries—even when, overall, it’s not clear that our healthcare is better. In fact, in some areas outcomes are worse.

We Can’t Fund SCHIP, But We Can Save Merck

Today, Bloomberg trumpeted the good news:  “Merck Profit Gains on Cancer Vaccine, Diabetes Pill.”

“Merck & Co., the third-largest U.S. drugmaker, reported a 63 percent gain in earnings,” Bloomberg reported, a victory made doubly by the fact that Merck has seen some rough times. “Competition from generics and the withdrawal of the pain pill Vioxx in 2004 over heart risks have pulled net income down 39 percent since 2001,” the story explained. Indeed, Vioxx gave Merck a black eye, and it’s still battling lawsuits in the courts. But Gardasil, Merck’s new vaccine to prevent cervical cancer, is turning out to be just the blockbuster the company needed. “Gardasil, introduced a year ago [already] has sales of $418 million”

Those of you familiar with my views on Gardasil may want to skip the below section, as it is pulled from an August post. I promise I won’t do this often, but this is an important subject and it’s example of how, if drug manufacturers and their lobbyists work quickly enough, they can sell their story to politicians and to the public before skeptics in the scientific community have a chance to weigh in. Remember the drug industry saying: “It’s important to sell a new drug while it’s still effective” (i.e. before people know too much about it).

On August 27, I wrote:

Earlier this month the FDA announced that the direct-to-consumer ads Merck has been using peddle its new cervical cancer vaccine, Gardasil, are “half-true . . .information currently being advertised could mislead the public.” 

Massachusetts Health Reform: The Canary in the Gold Mine?

Advocates for health care reform have been keeping an eye on Massachusetts, hopeful that its new health reform law will serve as a pilot program for the nation.

I’m much less hopeful than I was two days ago.

Yesterday I attended the Massachusetts Medical Society’s Eighth Annual Leadership Forum where I was one of four speakers. This year, the Society (which owns The New England Journal of Medicine)  focused on the cost of health care –with a special emphasis on funding universal coverage in Massachusetts. The new was not good. While the citizens of   Massachusetts believe that everyone has a right to health care (when polled 92% say “yes”), no one wants to pay for universal coverage.   When asked “if the only way to make sure that everyone can get the health care services they need is to have a substantial increase in taxes [should we do it] 55% said “no.”

One speaker at the forum recalled a man who explained why taxpayers shouldn’t have to pick up the bill: “The government should pay for it.” (He didn’t disclose who he thinks “the government” is. )

The FDA's Moment of Truth by Niko Karvounis

Soon we’ll see what the FDA is made of.

Yesterday the AP reported that “doctors told the Food and Drug Administration advisers that the over-the-counter [cough and cold] medicines shouldn't be given to children younger than 6 because they don't help them and aren't safe.” The final recommendation of an advisory panel of outside experts tasked with determining whether or not this is the case is due to the FDA late today.

By “not safe” petitioners don’t necessarily mean that the medicines themselves cause harm, but that they encourage reliance on “quick fixes,” an approach that can mask symptoms of more serious ailments.

This is obviously a problem in and of itself, but becomes an even a bigger deal when one considers that there are no known benefits to the medication. The drugs have never been tested on children—something the FDA has known since 1972. Instead, drug makers “have used extrapolated data from studies in adults to come up with dosing recommendations based on a child's age or size.” Hardly rigorous medical science.

The threshold for unacceptable risk is a lot lower when a medicine does nothing. Michael Shannon from the Children's Hospital Boston pediatrician and Harvard Medical School puts it best: “when a treatment is ineffective, its risks -- if not zero -- always will exceed its benefits.”

So what should worried parents do when their kids have a cold?

The Real Danger of Socialized Medicine by Niko Karvounis

Last week The Washington Post ran a good opinion piece by Ezekiel J. Emanuel, Director of the Clinical Bioethics Department at NIH (and brother of Congressman Rahm Emanuel) on the insidiousness of labeling any and all positions on health care apart from free market fundamentalism as being “socialized” medicine, doomed to failure.

Emanuel notes that “ ‘socialized medicine’ is when the doctors are state employees; when the hospitals, drugstores, home health agencies and other facilities are owned and controlled by the government…” As Emanuel rightly points out, none of the universal coverage proposals being debated in the U.S. today “can be characterized as socialized medicine. None calls for government ownership or control over U.S. hospitals, drugstores or home health agencies, or for making doctors employees of the federal or state governments.”

This is right on the money—maybe even more so than Emanuel intends. Opponents of “socialized” medicine are wrong three times over: not only do most reformers not want socialized medicine, but even European health care systems (often used as examples of socialized medicine) do not meet the criteria outlined above. Further, publicly-run health care carries with it some significant benefits that are evident right here in the U.S.

To dispel the myth of monolithic government-run European health care, look no further than Germany, where most of the population (88%) receives health care through “sickness funds"--non-profit, third-party pools of money devoted to health services. Sickness funds are built on the principle of “subsidized self-governance”: they receive public funding, but the funds must be financially self-sufficient (i.e. be able to govern themselves) and also allow a high degree of freedom on the part of patients and doctors (the former can choose their doctors and hospitals, and the latter have much flexibility in treatments).

Race and Health Care: Dimensions of Inequity by Niko Karvounis

Yesterday I talked a little about segregation of patients by race in NYC hospitals, and noted how this is likely a problem repeated across the nation. Wonder no more: a 2006 study in the Journal of the American Medical Association (JAMA) analyzed about 719,000 Californians who had received a wide range of complex surgeries. The authors found that blacks, Latinos, and Asians were far less likely to get these operations done at high-volume hospitals, which tend to have better outcomes for complex surgeries. (After all, practice makes perfect).

If you’re white, you’re more likely to receive care at high-volume, better-performing hospitals. This is bad in and of itself; but unfortunately, discrimination continues beyond the level of medical institutions and into the level of individual doctors. A 2004 study in the New England Journal of Medicine looked at the primary care experience of Medicare patients, specifically looking at 150, 391 visits by black and white Medicare beneficiaries for “medical evaluation and management who were seen by 4355 primary care physicians.” Here is what they found:

“Most black patients were confined to a small group of physicians (80 percent of visits were accounted for by 22 percent of physicians) who provided only a small percentage of care to white patients. In a comparison of visits by white patients and black patients, we found that the physicians whom the black patients visited were less likely to be board certified (77.4 percent) than were the physicians visited by the white patients (86.1 percent) and also more likely to report that they were unable to provide high-quality care to all their patients (27.8 percent vs.19.3 percent).

Why We Don‘t Have Enough Nurses (It's Not Low Wages)

Consider this: In the San Francisco area, a nurse with a bachelor’s degree can hope to start out with a salary of $104,000. The salary for a nursing professor with a Ph.D. at University of California San Francisco starts at about $60,000.

This goes a long way toward explaining why nursing schools turned away 42,000 qualified applications in 2006-2007—even as U.S. hospitals scramble to find nurses. We don’t have enough teachers in nursing schools and the fact that the average nursing professor is nearly 59 while the average assistant professor is about 52 suggests that, as they retire, the shortage could turn into a crisis. The most recent issue of JAMA (October 10, 1007) reports that in 2005 we had 218,800 fewer nurses than we needed and by 2020, it’s estimated that we’ll be short some 1 million nurses.

Hospitals have had to raise nursing salaries (as well they should), not just because nurses are scarce but because, in our chaotic hospital system, the work can be extraordinarily stressful.   

Race and Health Coverage: Medical Apartheid?

I've invited Niko Karvounis, a colleague at The Century Foundation, to guest-blog. Niko is currently a Program Assistant at the Foundation and an Alumnus Senior Fellow with the Roosevelt Institution. His post follows below.

....

Recently I was handed a report from Bronx Health Reach (BHR) entitled “Separate and Unequal: Medical Apartheid in New York City” that reveals some startling inequities right here in the so-called capital of the world.

Bronx Health Reach is a coalition formed by the Institute for Urban Family Health, with the mission of examining and addressing racial and ethnic health disparities in the southwest Bronx portion of NYC.

At the local level in the Big Apple, these disparities play out through discriminatory care tied to health coverage. Since “health insurance is a major determinant of access to medical care,” poor insurance increases the probability of “delayed care and poorer health outcomes.” And in NYC, health insurance status is closely linked to race: “52 percent of blacks, 63 percent of Latinos” and only “24 percent of whites are uninsured or publicly insured.”  This skewed distribution of health coverage ultimately “creates a de facto sorting of patients by race.”

The most compelling evidence of apartheid can be found in the records of medical institutions which reveal the characteristics of patients that they admit and discharge.

Do You Want to Know That You Will Be an Alzheimer Patient in Two to Six years?

Yesterday The New York Times reported a medical breakthrough: “the development of a blood test that can  accurately  diagnose Alzheimer’s disease, and even do so years before truly debilitating memory loss.”

Well, “accurately” may be a bit of a stretch. As the Times explained, the test is about “90 percent accurate in distinguishing the blood of people with Alzheimer’s from the blood of those without the disease” and “about 80 percent accurate in predicting which patients with mild memory loss would go on to develop Alzheimer’s disease two to six years later.”

Then, the Times acknowledged, there is one other problem with the test:  “At present, treatments for Alzheimer’s disease are not very effective.”

So why exactly would I want an early warning that would give me two to six years to contemplate what it will be like to observe my mind dissolving? (Of course I could comfort myself with the fact that the test is only 80 percent accurate, but somehow I suspect that would only compound my anxieties.)

“There are people who want to know what their future holds so they can plan their estates and lives,” Dr. Sam Gandy, a professor at Mount Sinai School of Medicine in New York who is chairman of the medical and scientific advisory council of the Alzheimer’s Association, told the Times.

Right, this is an estate planning tool.

When Women and African-Americans Receive Better Care Than White Men

Last week a new study in the Journal of the American Medical Association documented yet another case of discrimination in American medicine. It turns out that blacks and women suffering from heart disease are much less likely than white men suffering from a comparable level of disease to have a defibrillator (a cutting-edge device that uses a jolt of electricity to shock an erratically beating heart back to a normal rhythm) implanted in their hearts.

But as Merrill Goozner points out at GoozNews:  "Guess what? They may be the lucky ones, at least when it comes to implantable cardioverter-defibrillators (ICDS) . . ."

The study showed no benefit for the white men who received the implant. Below, Merrill's analysis, plus his comment (from a separate post) on the need for more and better research into the effectiveness of new drugs and devices:

More Thoughts On the Hospital Building Boom

A Startling Insider’s Look at What Happens to Patients Who Stay in the Luxury Suites of a Prestigious Hospital                         

Last week, thehealthcareblog.com (THCB) asked if they could put up my post about the hospital building boom below where I ask “Can we Afford the Waterfalls”-- and all of  the other hotel-like amenities that new hospitals are beginning to offer. Do we really need grand pianos, valet parking and all-private rooms—especially in hospitals that don’t yet have electronic medical records? (See my original post here)          

Quite a few readers at THCB commented, with a number voting “yes” for the amenities.  But one young doctor said “no”—and then offered this startling insider’s  view of  the care patients do and don’t receive on the luxury floor of one prestigious hospital:

“Maggie's right-on regarding the disconnect between hospital frills and quality of care...

How Not-For Profit Hospitals Hooked on Growth Can Help Bankrupt the System

In response to the questions I raised in two posts below about the hospital building boom and whether we need—or can afford—hotel-like amenities, Dr. Terry Bennett sent HealthBeat the story below. It’s a provocative insider’s look at how a local hospital is raising the money for an “expansion” that, according to Bennett, seems to have very little to do with improving the health of its patients or the local community. Part problem is that CEO’s of non-profit hospitals have begun to think like CEO’s of for-profit corporations: growth is always good.

“If you own all of the doctors’ practices that refer to a community hospital—as the CEO of our local hospital does-- you can dictate where, when and for how much every single patient is seen,” Bennett writes.” For example, you can make sure that all urgent cases are seen in your hospital’s ER at $1000 a head. (Medicare and Medicaid pay less than a grand for a "bare bones" ER visit, but if you order an EKG, an x-ray or two, and a few lab tests, you can push the visit up to over $1000).

“Do that 100 times a day and you have millions [of dollars] which you need to cause to vanish as quickly as possible. [Otherwise the Centers for Medicare and Medicaid services may question how a not-for-profit could be making such rich profits, and start to examine your books.] Thus the Atria, the waterfalls,the new facades, the many other flashy dashy add-ons, the services no body really needed.

“The CEO of our local hospital hates me. Because my patients can reach me 24/7, I have the lowest ER admission rate of any physician on the staff at my local hospital. I treat over the phone, see the next day, am always on the prevention line of chatter, etc. [In other words Dr. Bennett is not helping the CEO fill the hospital’s coffers].

“Meanwhile, our hospital, is in the midst of a $45 Million ‘expansion’--- no new beds, no new services, but $45 million is being buried, and ‘non profit status’ is preserved. It is happening in almost every community across the USA. Such antics make any healthcare budget, Medicare, Medicaid, or HMO, completely unpredictable and are bankrupting the entire present system and all of its budgeting assumptions—and will continue to do so until forcibly stopped.”

Dr. Bennett also included a copy of an Op-ed which originally appeared in two New Hampshire newspapers, the Portsmouth Herald and the Rochester Times. Below, an edited version:

Health care issues in the new millennium
By Dr. Terry M. Bennett

It seems like only yesterday, but it was in fact 16 years ago, 1992, when I ran for a New Hampshire Senate seat proposing a single-payer Medicaid-based national health care plan using our Social Security numbers for identification.

Are We Willing to Accept a Two-Tier Hospital System?

Yesterday, I wrote about the hospital-building boom and suggested that we may not need it—and more to the point, we may not be able to afford it.

In my description of how hospitals are adding costly amenities like waterfalls and all-private-rooms in order to woo well-heeled, well-insured patients, I suggested that the money might be better invested in computerized medical records or Level I trauma units. (In some parts of the country, trauma units are spaced so far apart that if you are in a car accident, there is a real danger that the unit will be too far away to be of any help.)

Barry Carol responded, agreeing that safety should come first, but also arguing that the private rooms help prevent infections. As for the waterfalls, he noted that “while they may make good journalistic copy as illustrative of frills,” given the high cost of hospital construction “they probably get lost in the rounding as a cost factor.” See his comment here.

Because Barry had raised a number of good points, and because the hospital boom is such a large and crucial subject, I decided to return to it today while responding to his comment.

Barry—

I'm afraid the waterfalls are more than good copy for journalists.. Similar amenities are being included in hospital construction across the country--and it adds up.

The Hospital Building Boom: Can We Afford the Waterfalls?

In Money-Driven Medicine: The Real Reason Health Care Costs So Much I talk about the nationwide hospital building boom—and ask two questions: Can we afford it? Do we need it?

In many regions, suburban hospitals have been reaching for big-city business. “What we have to do to maintain our position in the markets is to keep adding services,” explained Westchester Medical Center CEO Ed Stolzenberg. “That’s the whole reason we went into liver transplants.”

Did the resident of Westchester Country (just outside of New York City) need a local hospital doing liver transplants? Just how many transplants would a Westchester hospital do? Would such patients be better off at a high-volume medical center in Manhattan where “practice makes perfect”?

Those questions didn’t seem to come up.  The CEO knew that transplants would raise the hospital’s image.

Across the nation, as not-for-profit hospitals set out to invest in new construction and equipment, decisions seemed to be market-driven—but  not necessarily driven by the local population’s medical needs.  Instead, they were powered by the hospital’s need for market-share.

Employers and Healthcare: “Which Frogs A-Leaping?”

At “Healthcare Renewal” (hcrenewal.blogspot.com) Brown University’s Dr. Roy Poses recently posted a thought-provoking piece about the Leapfrog Group, an employer group that has made its reputation pushing for higher quality care.  Poses points out that nearly 30% of the members of Leapfrog are healthcare corporations, and notes that this might skew their view of healthcare’s goals:  

“One would expect that companies who make money by providing health care goods and services may have different ideas about health care costs and quality than companies who do not do any health care related business” said Poses in his post.

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Inside the FDA

I was speaking to a source inside the FDA recently and he explained that since the FDA has committed to reviewing applications for approval of a new drug within 10 months, drug-makers have been submitting “shabbier” applications that contain less evidence about risks and benefits.

“For the drug-maker it’s a gamble. The company is betting that, because we want to make the 10-month deadline, we won’t send the application back,” said the source. And often, he acknowledged, the drug-maker is right. “If you find a problem or there is something missing and it doesn’t seem terribly material, there is a tendency to overlook it. Because if you don’t it will just delay the whole process.”

In the past, he adds, a company submitting an application knew that if the application wasn’t up to snuff, the FDA would send it back. But those standards have fallen: “Now we send it back [only] if it’s really crappy.”

We also talked about direct-to-consumer advertising and why many in the pharmaceutical industry resisted the suggestion that they wait two years before trying to sell a new drug directly to the public. “There is a saying in the industry,” he confided, “[that] you want to get doctors accustomed to using a new drug while it still ‘works’—while it’s still the latest and the greatest.”

In other words, drug-makers want doctors to begin using the drug before everyone discovers that it is not quite the miracle cure that some hoped it would be. Knowing that it takes time to discover the risks of a drug, doctors might not be so quick to take up the absolute newest thing on their own. That’s why companies like to go to consumers who they hope will push their doctors into trying the new products before all the risks are known.

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Preventing Hospital Errors by Howard C. Berkowitz

I have asked Howard Berkowitz to guest-blog on hospital errors.

Howard is in an unique position to write on this topic because he consults on medical information systems for hospitals and also has been a long-time patient. Over the years, he has taken an unusually detailed decision-making role in his own care for heart diseases and diabetes which, he says, “has kept me going, with bad heart genetics, at least 17 years more than my father.”

Howard also reports that “when no one else would coordinate my mother’s complex cancer care, I did so...and I know what it is to preserve the semblance of life, when only pain remains. Complex pain management is also one of my interests; too few doctors know that pain should always be controllable.”

As a result of his own health problems and his parents’ illnesses, he has spent more time in hospitals than anyone would ever want to endure. But unlike most of us, he understood what was going on. Originally trained in microbiology and biochemistry, Howard was doing independent research in antibiotic resistance and working in a clinical laboratory while in high school. He confesses that, for his 10th birthday, he asked his mother for a copy of the Merck Index of Chemicals and Drugs. Subsequently, he built the first clinical computer system for Georgetown University Hospital, developed virological systems for Electronucleonics’ “hot lab” and developed cardiac care simulators and for the George Washington University School of Medicine, Office of Computer-Assisted Instruction. He also developed the first automated blood bank laboratory tools for the Red Cross.

Full disclosure—he has two patents in process for hospital communications and staff management dedicated to keeping them informed, in real time, of patient needs. His post follows below.

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Preventing Hospital Errors Part II by Howard C. Berkowitz

Given the medical community’s reluctance to step up and admit to mistakes, Medicare has decided to get tough, saying that it will stop reimbursing  hospitals for the thirteen adverse advents listed below. Before discussing the list, let me suggest that not all of these events are within a hospital’s control. I’ve rated the mishaps on the list from 1 to 4, with “1” indicating something that, I agree, should never happen, and “4” referring to something that, in my experience, a hospital may not be able to prevent.

    The 13 Things That Should Never Happen in a Hospital
   1. Catheter-associated urinary tract infection [2]
   2. Bed sores [1]
   3. Objects left in [THE PATIENT”S BODY] after surgery [1]
   4. Air embolism, or bubbles, in bloodstream from injection [1]
   5. Patients given incompatible blood type [1]
   6. Bloodstream Staphylococcus (staph) infection [2]
   7. Ventilator-associated pneumonia [2]
   8. Vascular-catheter-associated infection [2]
   9. Clostridium difficile-associated disease (gastrointestinal infections) [3]
  10. Drug-resistant staph infection [3]
  11. Surgical site infections [3]
  12. Wrong surgery [1]
  13. Falls [4]

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