How the Media Covers Health Care

Sometimes health care reporters remind me of the financial journalists who helped hype the bull market of the 1980s and 1990s. I began my career as a journalist at Money magazine, and I remember sitting in an editorial meeting where we talked about an upcoming cover story: “The Ten Best Mutual Funds NOW.”  One intrepid reporter asked: “What if there aren’t ten great mutual funds that you really should invest in right now?”

“Let the fact-checker worry about that,” someone else quipped, referring to the person who would be double-checking the details of the story just before it went to press. Almost everyone sitting around the table laughed.

And Money was generally a pretty responsible magazine that tried to warn investors against the risks of the market. Still, “good news” cover stories sold magazines—just as “breakthrough” medical stories on the local evening news keep viewers from changing the channel.

Gary Schwitzer, an associate professor in the School of Journalism and Mass Communication at the University of Minnesota, recently published a provocative piece about how the media covers health care in the American Editor. Schwitzer begins his piece by asking his reader to “Imagine a reporter filing a story from the Detroit Auto Show. She writes about one car maker’s hot new model as if it is the best thing since the ’57 Corvette. But in the excitement over the chrome and style, she doesn’t mention the cost of the new model, doesn’t compare it with other manufacturers’ offerings in the same class, and doesn’t mention anything about performance (fuel efficiency, handling, braking, safety issues, etc.)

“An editor would certainly raise questions about this kind of puffery.

“But over on the health care beat,” Schwitzer observes, “the majority of stories on new products, procedures, treatments and tests are published without including comparable information. Claims that would never be accepted unchallenged from a politician are accepted unquestioningly from physicians and researchers and company spokespersons.”

Schwitzer, who publishes HealthNewsReview.org, a website that grades health care news stories for accuracy, balance, and completeness, has evidence to back up his claim.  Below I’ve re-posted some of his data on some 400 stories from almost 60 major news organizations (available at his website) to demonstrate how many health care stories “provide a kid-in-the-candy-store portrayal of the health care system that leaves readers with the impression that most products or procedures in health care are amazing, harmless and without a price tag”:

The Best Health Care Posts

Check out this week's Health Wonk Review, highlighting the best stories that have appeared on health care blogs in the past two weeks--including a post about “the sorts of people some pharmaceutical companies hire to perform clinical research . . . including one physician-researcher who managed to personally give two of his patients genital herpes . . .”

Health Wonk Review also throws a spotlight on Managed Care Matters, where Joe Paduda recently examined how US universal coverage plans could deal with illegal immigrants, but noted that meanwhile, Mexico may come up with a universal coverage system before the US does.

And on the Agonist Ian Welsh commented on John Edwards’ pledge that if Congress doesn’t pass universal health care by July 2009, “I’m going to use my power as president to take your [legislator’s]  health care away from you.” Time magazine’s Joe Klein was appalled, calling Edwards’ statement “demagogic nonsense.” Welsh disagrees. ( I would be interested in what Health Beat’s readers think.)

This week, Dr. Roy Poses picked the posts for Health Wonk Review.  The editor of Health Care Renewal, Poses specializes in “addressing threats to health care's core values, especially those stemming from concentration and abuse of power.”  I began talking to Poses before I started this blog, and I have the greatest respect for his work. He pulls no punches, and backs up his pieces on conflict of interest and fraud with excellent research.  Honest physicians know, better than anyone, what is going on in our health care system, and Poses is one of the guys carrying a torch.

Is State-Level Health Care Reform Doomed?

It’s a waste of breath to say that health reform is a big issue in the states. But is it also the case that health reform in the states is a waste of time?

With health reform experimentation popping up across the nation, conventional wisdom has become, as Massachusetts State Senator Richard T. Moore put it in a blog post for the Commonwealth Fund, that states are “critical laboratories for quality and innovation.”

Yet while Moore is right to say that “common elements of success will serve as a useful learning experience for other states and national leaders in considering more comprehensive health care reform,” there’s another side of the issue to consider: there may be some states that can’t sustain universal coverage without more comprehensive federal reform—no matter how insurance programs are designed. There’s also a danger that failure at the state level could be used to argue that comprehensive health reform is simply an impossible goal.

Among the biggest problems with universal coverage is cost: how can we afford to insure everybody? One answer is to require that everyone buy coverage.  By mandating insurance, a state can spread the cost across a larger pool of people that includes low-risk individuals who can help share the burden of insuring high-risk individuals.

Without a mandate, no one would buy insurance until they were sick or elderly; the pool would be made up of people who are expensive to insure, and soon coverage would become unaffordable. The only alternative would be to pass laws saying that if you don’t sign up before you become sick, insurers have the right to refuse to cover you –or to charge you five times what they would charge a healthy person. This is what happens in many states today, which is why one serious illness can send a family into bankruptcy. If we want to say that insurers can’t leave anyone out in the cold—even if they are very sick –then we also have to say that everyone must participate in the system.

The question remains:  will mandates work at the state level?

Consider Maine. In 2005, Maine launched the nation’s first experiment in universal health coverage through the “Dirigo Health Act,” named after Maine’s state motto, “Dirigo,” Latin for “I lead.” Dirigo is entirely voluntary, and as a result only 18,800 people (most of which already had private sector insurance) have signed up for DirigoChoice, the main arm of the program devoted to small businesses and individuals. Meanwhile, some 130,000 Maine residents remain uninsured.

The Unhappy Legacy of Medicaid

In September, the non-profit organization Public Citizen (PC) issued a report comparing Medicaid and Medicare payments to doctors in 10 states and Washington D.C. The results underline the fact that Medicaid has been designed, from day one, to give states an easy  cop-out when it comes to health care for the poor.

The study highlights cases where the disparities between what different states pay a doctor to care for a Medicaid patient are greatest: “In New York, doctors are paid $20 for an hour-long consultation with a Medicaid patient, while in higher-paying states, doctors receive an average of $157.92 for the same service – a difference of greater than sevenfold. The difference within a state between what Medicaid pays [a physician to treat a patient who is poor enough to qualify for Medicaid] and what Medicare [pays a doctor to care for an elderly patient] is just as dramatic. For this hour-long consultation, a physician in New York could earn $196.47 from Medicare, almost 10 times more than from Medicaid.”

Last month the AMA posted a chart of these and other disparities on its medical news website, and seen side-by-side, the comparisons are startling: a physician in New Jersey or Pennsylvania gets, on average, about one quarter as much for seeing a Medicaid patient as a Medicare patient; in New York and Rhode Island, less than a third; and in the nation’s capital less than half as much. Other states lie at the other end of the spectrum. Alaska, Wyoming, Delaware, and North Carolina all pay more for Medicaid than Medicare.

Is there any rhyme or reason to how states reimburse Medicaid care? Looking at Alaska (which pays more for Medicaid, relative to Medicare, than any other state) and New Jersey (which pays the least) it initially seems that poverty rates may factor into disparities. Alaska’s poverty rate is the 7th highest in the nation, so it would make sense that it would want to encourage health care for the poor. New Jersey, on the other hand, is almost last in the nation when it comes to poverty rates (no. 47 on the list) so the state may not feel as strongly about the need to ensure care for the poor.

The New York Times “Gets Cracking” on Rising Health Care Costs

On Sunday the New York Times published an editorial that set out to analyze “The High Cost of Health Care.” The result might best be described as “muddled.”

What is exasperating is that about 85 percent of the facts in the editorial are true. But a good 15 percent are simply wrong.  And the Times’ editors managed to weave truth and error together in such a way that it would take a knitting needle to separate the two. As Matthew Holt put it on The Health Care Blog: “the piece looks entirely as though it was written by a committee that couldn't agree with itself.”

As you read the editorial, you can almost see the editors sitting around a table, negotiating. “Okay,  we’ll let that sentence about the value we’re getting for our dollars stand—as long as well keep this sentence about  ‘skin in the game.’”  The result, a mix of propaganda and analysis, is far more dangerous than outright lies because the many true facts make the whole thing sound credible.   

Because I hate to see our paper of record disseminate disinformation, I am going to try to separate the wheat from the chaff. Begin with the truth: Near the top of the story, under a sub-head that reads “Varied and Deep-Rooted,”  the Times provides a nice summary of the main reasons why we lay out roughly twice as much as the average developed nation, without getting care that is twice as good:

“we pay hospitals and doctors more than most other countries do. We rely more on costly specialists, who overuse advanced technologies, like CT scans and M.R.I. machines, and who resort to costly surgical or medical procedures a lot more than doctors in other countries do. Perverse insurance incentives entice doctors and patients to use expensive medical services more than is warranted. And our fragmented array of insurers and providers eats up a lot of money in administrative costs, marketing expenses and profits that do not afflict government-run systems abroad.”

Spot on. If only this section of the editorial had not begun with a casual half-truth: “Contrary to popular beliefs, this is not a problem driven mainly by the aging of the baby boom generation, or the high cost of prescription drugs, or medical malpractice litigation that spawns defensive medicine.”

They first part of the sentence is correct: the aging of the boomers is not a major cause of health care inflation.  The last clause of the sentence is debatable, though probably true.
What’s troubling is the middle clause:  Why does the Times feel obliged to declare that the “high cost of prescription drugs” is not an important factor behind soaring medical bills?

Health Care Reform: What Do Americans Want? (Or Think They Want?)

On the surface, it seems that American voters have made their will clear.  Poll after poll shows that they are calling for a major overhaul of our health care system.

But when you look closer, their responses bristle with contradictions, contradictions that I think the reform-minded presidential candidates will have to consider when deciding how to approach health care reform. 

In a poll reported in Health Affairs at the end of last year, sixty-nine percent of respondents rated the US system as “fair” or “poor.” Yet in the same survey, when asked about their own experience with receiving medical services or with their own physician, 80 percent who had received care in the last year ranked their care as “excellent” or ”good.”

Other polls reveal the same pattern.

According to a survey released by Greenberg Quinlan Rosner in July, voters express doubts about the quality of the American health care system (with 49 percent dissatisfied), while 74 percent were dissatisfied with the cost.   Yet, “at another, more personal level,” the pollsters note, “a slightly different picture emerges. Fully eight in ten (82 percent) describe themselves as satisfied with the quality of the health care they receive personally. This number jumps to 90 percent among seniors (64 percent very satisfied), but includes impressive majorities of nearly all groups…”

Nevertheless, when the pollsters asked the same group about health care reform, three-quarters called for “major changes” or “completely rebuilding” the system. 

If they are satisfied with the care they are receiving, why would they want radical change? Because they don’t feel secure that they will be able to keep what they have:  “There’s a precariousness to Americans’ contentment with their own health insurance coverage,” the Kaiser Family Foundation reported after looking at a number of polls at the end of last year.  “Among the insured, six in ten are at least somewhat worried about being able to afford the cost of their health insurance over the next few years, and nearly as many (56 percent) said they worry that by losing a job, they or their family might be left without coverage.”

This, then, is why so many Americans want universal health care: it would guarantee that they and their families would always be covered.

Conditional Cash Transfers: An Interim Model for Health Care Reform?

This past September, New York City’s Mayor Bloomberg welcomed 5,000 families into the pilot program of Opportunity NYC-- the nation’s first conditional cash transfer (CCT) program. Based on a Mexican program called Oportunidades, CCT programs like Opportunity NYC (ONYC) provide financial incentives for poor households to “meet specific targets” in three areas: education, employment/training, and health.

I recently spoke with Héctor Salazar-Salame, Advisor to the Center for Economic Opportunity, which operates ONYC, about the health components of the program. I wanted to get an idea of the aims and strategy behind ONYC—and also to learn more about CCT as a potential model for thinking strategically about health care reform. 

According to the city’s press release, ONYC’s health incentives will be offered “to maintain adequate health coverage for all children and adults in participant households as well as age-appropriate medical and dental visits for each family member.” In terms of coverage, families can earn “$20 or $50 per adult per month for maintaining health insurance and $20 or $50 for maintaining health insurance for all the children in the family.”

The point is to encourage low-income families to enroll in health insurance plans. “Many families work for employers that offer insurance,” Salazar-Salame explains, but “many times the necessary employee contribution is quite high for low-income families. We’re providing an incentive for families to opt into their work-based, private health plan—and hoping that the incentives will help them offset the cost of the employee contribution.”

If parents are unemployed—or work for employers that don’t offer coverage—the family can still be eligible for health incentive rewards that keep them enrolled in Medicaid. “We know that to recertify for Medicaid can be a challenging yearly process that takes a lot of time,” says Salazar-Salame. (It’s worth keeping in mind that roughly 30 percent of parents who don’t manage to enroll or re-enroll their children in Medicaid have less than a high school education).  “We’re hoping the incentive will help them maintain the insurance that they’re eligible for,” Salazar-Salame explains.

Maintaining insurance is harder than it sounds. In October, Maggie wrote about  just how difficult it can be to stay enrolled in Medicaid and SCHIP, pointing to a Health Affairs article titled "Why Millions of Children Eligible for Medicaid and S-Chip Are Uninsured."

How Wall Street Reacts to Fraud in Our Health Care Industry

This appeared on Bloomberg News today:

“WellCare Shares Jump After Analyst Calls Fraud Probe `Limited'

Nov. 20 (Bloomberg) – WellCare Health Plans Inc., the U.S. health insurer under investigation for possible government overpayments, rose the most in two weeks in New York trading after an analyst upgraded the company.

“The analyst, Carl McDonald of CIBC World Markets in New York, called the probe ‘limited’ and raised his rating of WellCare to ‘sector outperform-speculative' from ‘sector perform.' WellCare rose $2.38, or 6.8 percent, to $37.39 at 9:40 a.m. in New York Stock Exchange composite trading after touching $38.14.

“A U.S. government raid of WellCare's Tampa, Florida, headquarters on Oct. 24 yielded thousands of records, including papers pulled from a shredder bin and files on offshore bank accounts, according to court filings. McDonald said the filings suggest the probe is focused on Florida's Medicaid program for the poor.

“’It's possible that the Florida Medicaid investigation spreads into other areas, but the document seems to rule out widespread, systemic fraud,’ the analyst said in a note to clients today.”

Bloomberg also reveals that: “The agents seized records from the desks of Chief Executive Officer Todd Farha and Chief Financial Officer Paul Behrens, according to the court records. From Behrens' desk, agents grabbed a document called the ‘Stairway to Heaven Plan,' according to the inventory.

“Also taken were wire transfers, tax returns, bank accounts in the Grand Cayman Islands, a calendar of political visitors and contributions, and phone lists. One seized document was labeled ‘Re: Possible Kickback,’ according to the court records”.

Yet none of this seems to bother the analyst who upgraded the stock or the many investors who followed his upgrade--pushing the share price up 6.8 percent this morning.  The analyst predicts that “that WellCare [will] settle, pay a fine, but remain in all its businesses, rather than being put out of business.”

Herzlinger’s Meme on Switzerland and Consumer Driven Medicine

In today’s Wall Street Journal, Harvard Business School professor Regina Herzlinger offers an upside-down account of what’s right and what’s wrong with Switzerland’s health care system.  A leading advocate of “consumer driven” health care, Herzlinger assumes that because the Swiss pay for so much of their care out of their own pockets, consumer choice drives their system. 

But the truth is that Swiss patients have relatively little say over either the cost or the quality of the care they receive. Prices are regulated by the government, which also tries to make sure that consumers are getting value for their health care dollars by selecting which drugs, devices and tests insurance will cover. In fact, it is the very visible hand of a smart, largely efficient government that accounts for Switzerland’s relative success.

Before explaining how Herzlinger gets so much so wrong, let’s look at what she gets right. “The Swiss have achieved universal coverage,” Herzlinger points out “at a far lower cost than the U.S.”  In 2003 Switzerland spent 12 percent of GDP on health care while we laid out “a staggering 15 percent of GDP” while leaving roughly 14 percent of our population uncovered. Switzerland also has “far better health outcomes than the U.S., even when Switzerland is compared to socio-demographically similar U.S. states such as Connecticut and Massachusetts,” Herzlinger acknowledges. Moreover, while U.S. insurers in most states can shun sick customers, either by refusing to cover them—or by charging them astronomical premiums—in Switzerland you are not penalized for having cancer. The sick “can afford health insurance and pay the same price” as everyone else.

Finally, while the cost of care continues to snowball in both countries, the Swiss seem to have a better handle on health care inflation. From 1996 to 2003 health care spending in Switzerland rose by an average of 2.8 percent a year, Herzlinger says, versus 4.1 percent in the U.S.  Meanwhile “Switzerland boasts substantially more in the way of health-care resources and . . . tops the world in most measures of user satisfaction.”

Does the U.S. Have Too Many Doctors?

On the Buckeye Surgeon blog, a general surgeon from Cleveland, Ohio, questions what he calls “the almost dogmatic assumption that the United States is facing a physician shortage is the coming years…We're always reading that we need to train more doctors, that with the aging population there won't be enough physicians to satisfy demand. But then I was waiting for the elevator the other day, reading the names of all the doctors on the peg board who practice at one of my hospitals. The board is 4x4 feet and just crammed with names, names, names. It's unbelievable how many doctors there are.”

“There's two large GI groups,” Buckeye Surgeon continues. “There's three general surgery groups. There's three separate pulmonary groups. The ID group has 7 doctors. (Don't get me started on ID again). And on and on. What we have isn't a physician shortage, but rather a physician overabundance. And I don't think it's too different at most suburban hospitals across the country. The scenario isn't one of overworked doctors struggling to keep up with the demands of patients waiting in line for care. Rather, it's a hyper-competitive world of doctors in the same specialty fighting over a limited supply of patients.”  (Thanks to Kevin, M.D. for calling my attention to Buck Eye’s post.)

Buck Eye Surgeon is offering an anecdotal view of physician supply, but rational research backs up his claim. When the Council on Graduate Medical Education (COGME) warns that we need to train more physicians to meet the demands of aging baby boomers, the Council assumes that the current national physician-to-population ratio is optimal.  Those who call for more physicians “never examine the relationship between physician supply and the health of patients and population” notes Dartmouth’s Dr. David Goodman in a 2005 Health Affairs article, “The Physician Workforce Crisis: Where Is the Evidence?” (For more about Dr. Goodman, his background and his evidence, see "David Goodman, M.D.: Counting All Doctors" in Dartmouth Medicine )

Take a look at the evidence, and it’s clear that the conventional wisdom is wrong. As I’ve discussed in the past, in areas of the country that boast more specialists, patient outcomes are worse—even after adjusting for differences in age, race and the overall health of the population. (I have written about this for both Health Beat and Dartmouth) A greater supply of primary care physicians, on the other hand, leads to better outcomes. So, Goodman quite sensibly concludes: “If improving the health and well-being of the population remains our goal we need more generalists and fewer specialists, today and in the future.”

ADHD and the Medication Feeding Frenzy in America

CORRECTION: In the post below, I make mention that there has been no U.S. media coverage on the MTA report. But after some further digging, I found coverage from Investor's Business Daily, along with popular sources the New York Post, and Fox News and technical/niche publications like Planet Chiropractic. So there is some American coverage.

But if you click around you can see that the American stories are much more brief than their international counterparts. Each of the stories in the mainstream outlets is more of a newswire dispatch than an actual article, where as the international stories are comprehensive. And while pretty much all of the news sources of record in the U.K. covered the story, the major U.S. outlets--like the WSJ, NYT, Time, Newsweek, etc--seem to have had nothing.

Given that the U.S. is 90 percent of the ADHD drug market, you'd think that MTA's findings would make nation-wide headlines. But instead coverage is scattered and superficial. Stories are relegated to quasi-interest group literature (investors who may lose money on the drugs, chiropractors who have a professional interest in questioning medication), or to the News Corporation (which owns both the Post and Fox news)--a multinational company with a strong Australian and British component. There's still no convincing evidence that the American media is, on the whole, ready to meaningfully cover MTA's findings.

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Earlier this week the British press broke some startling news: the Multimodal Treatment Study of Children with ADHD (MTA), has issued a report that claims there are no long-term benefits of ADHD medication for hyperactive children. Report co-author Professor William Pelham of the University of Buffalo, is quoted in the British press as concluding that ADHD medication is, in the long-term, all risk and no reward.

“The children [on ADHD medication] had a substantial decrease in their rate of growth so they weren't growing as much as other kids both in terms of their height and in terms of their weight,” he says. “And…there were no beneficial effects - none.”

This is an about face from MTA’s benchmark report in 1999 that asserted with certainty that ADHD drugs were the best way to address ADHD in children. The 1999 study claimed that “combination treatments” (i.e. drugs and behavioral training) along with “medication-management alone” (i.e. drugs) are “both significantly superior” to other ADHD treatments that don’t include medication.

But, according to Pelham, “we exaggerated the beneficial impact of medication in the first study. We had thought that children medicated longer would have better outcomes. That didn't happen to be the case.” So, according to Pelham, here’s the bottom line: “in the short run [medication] will help the child behave better, in the long run it won't.”

To some, Pelham’s report might be unwelcome news. Thanks in part to the medical credibility that MTA and other studies have conferred on ADHD medications, global sales of ADHD drugs are predicted to be $4.3 billion by 2012. This ADHD boom is a recent phenomenon, largely a product of the 1990s. According to the US National Ambulatory Medical Care Survey, the number of children who received a diagnosis of ADHD increased 250 percent from 1990 to 1998. A study from 1996 showed that from 1990-1995 child use of ADHD medication increased by a factor of 2.5 and drug production increased six-fold. The production of Ritalin (the most common ADHD medication) increased by 700 percent from 1990-1999.

Desperate, Drug Makers Court Doctors in Developing Countries

In the U.S. we are accustomed to seeing exceptionally well-dressed drug company reps strolling into doctors’ offices bearing trinkets: coffee cups, note pads and pens. We also know that they take doctors to expensive dinners, and host “continuing education” junkets to warm climes. Device-makers have been known to ferry doctors to strip clubs after dinner.

But in the developing world, drug makers are pulling out all of the stops. Often there is not even a pretense that the gift will help the doctor do his job. In Kashmiri, a physician confides, “representatives of pharmaceutical  companies offer cash, refrigerators, color televisions, laptops, PCs, mobile phones, ovens, phone bills, [and even to pay school] tuition [for your] children.”

In India, a doctor from Mumbai reports:  “On sale of 1,000 samples of the drug, you get a Motorola handset. On sale of 5,000 samples you get an air cooler. On sale of 10,000 samples get a motor bike.”

In Pakistan, a survey of 149 doctors, 100 medical information officers (sales representatives) and 99 medical store personnel, found that gifts may include included air conditioners, cars, cash, home appliances and domestic cattle.   Murad M. Khan, professor & chairman of the department of psychiatry at Aga Khan University, describes the latest practice: For writing 200 prescriptions of a company’s high-priced drug, a doctor is rewarded with the down payment on a brand new car.

These are just a few of the enticements documented in a November 2007 Consumers International (CI ) study, "Drugs, Doctors and Dinners: How Drug Companies Influence Health in the Developing World." (Thanks to Gary Schwitzer, at Schwitzer Health News Blog, for calling attention to this report.) A global voice for consumers, CI is an independent not-for-profit boasting over 220 member organizations in 115 countries.

Health Beat Hosts Health Wonk Review

Today, Health Beat is hosting Health Wonk Review, a biweekly compendium of the best of the health policy blogs. More than two dozen health policy, infrastructure, insurance, technology, and managed care bloggers participate by contributing their best recent blog postings to a roving digest, with each issue hosted at a different participant's blog.

Thanks to all of you for your submissions. I couldn’t do justice to all of them, but here’s a sampling of some of the best posts about health care on the blogosphere:

At Health Care Policy and Marketplace Review Robert Laszewski takes on Mitt Romney’s assertion that there are “pots of money” in the states –enough to allow states to follow Massachusetts’ initiative and fund health care reform without raising taxes. Laszewski demolishes the argument, pointing out that even Massachusetts doesn’t have enough money to follow Massachusetts’s initiative. That’s why the state has had to exempt some citizens from the mandate that everyone buy insurance.

On Health Access California, Anthony Wright offers the clearest explanation I’ve seen of Governor Schwarzenegger’s plan for reforming care in California, and its merits and limitations when compared to both HRC’s proposal and the Romney plan in Massachusetts.

On Physician Executive, Zagreus Ammon’s ambitious post “Defining Universal Health Care” begins by addressing the theory that each of us is responsible  for our own health—i.e. “that people do well because they make good choices and people do poorly because of poor choices.”

Here Ammon is responding to Peter Huber of Manhattan Institute fame and his editorial in IBD (Investors’ Business Daily) arguing that universal healthcare is an idle dream because eventually, the “pocket-book healthy” (read: wealthy) will get tired of paying for the “health-careless people” who don’t “live informed, disciplined lives”(read: less well-educated and poorer.) The righteous would rather see that money funneled into products that would provide them with “better hair, skin and sex,” Stern suggests.  For a more generous synopsis of Huber’s argument, see H.G. Stern’s rave review on Insureblog. 

Autism—Another Epidemic?

Does your 6-month old make eye contact?  Does your 8-month old follow your gaze? Does he mimic your facial expression if you show fear, anger or pleasure?

If you answered “no” to these questions, the American Academy of Pediatricians (AAP) wants you to know that your child might be suffering from Autism Spectrum Disorder (ASD). Just two weeks ago the Academy sounded the alarm in a report calling for screening of children under two, listing signs of autism which pediatricians and parents should watch for. The report appeared in the November issue of the journal Pediatrics and on the group's website.

At one time, autism was considered a rare disease. When I hear the word, I think of Dustin Hoffman’s brilliant performance in “Rain Man,” where he acts the part of an obsessive-compulsive idiot savant, imprisoned in his own tiny world of repetitive behavior. Rain Man is almost incapable of social interaction; it seems clear that he is afflicted with an uncommon disorder. But the Academy’s report begins by warning that, today, autism is not rare. One out of 150 children suffers from ASD, we are told. That’s why it is important to begin screening for the disease at an early age.

According to the AAP, doctors and parents should keep an eye on even the youngest children. For example, the report explains that “turning consistently to respond to one’s own name is an early skill that parents should expect to see in an 8 to 10-month old.”  The absence of this skill is said to be an autism warning sign. Other signs of trouble include “lack of warm, joyful expressions” when the parent points to an object and the baby gazes at it.  And by 9 months, says the report, the baby should be babbling—otherwise parents should be worried.

The AAP offers a brochure, entitled “Is Your One-Year-Old Communicating with You?”, developed to help raise parent and physician awareness and to promote recognition of ASD symptoms before 18 months of age. (The AAP advises that pediatricians give the brochure all parents at the child’s 9 or 12-month visit.) Different children “present” differently, the report observes, but some particularly vigilant parents may still be able to “perceive that their child is ‘different’ during the first few months of life.”

Your Yearly Physical Is a Waste of Time

…or at least that’s what some experts have increasingly been suggesting. According to the American College of Physicians (ACP), instead of having an annual physical, “healthy adults should undergo a much-streamlined exam that’s focused on prevention every one to five years depending on a person’s age, sex and medical profile.”

So what does that mean, exactly? According to the U.S. Preventive Services Task Force, doctors should focus on “interventions that help patients change health-impairing habits or that spotlight emerging illnesses for which reliable and effective treatments exist.”  These include “Pap smears, mammograms, cholesterol tests, blood-pressure checks, and counseling to stop smoking, lose weight, get more exercise and eat a healthier diet.” In other words, rather than just checking for everything, doctors should focus on interventions that can be substantively linked to treatments we know work. Currently, most check-ups are comprehensive run-throughs that seem to be administered  just for their own sake, regardless of how, or even if, they relate to meaningful treatments.

For many of us, the annual physical is a fixture of our health care experience, something we assume to be both necessary and desirable. Indeed, a study released last month found that 64 million Americans a year get a physical or gynecological exam, costing a total of $7.8 billion.  Regular gynecological exams are important—they include Pap smears that have made cervical cancer a rare disease. But the point of the general physical is less clear.  More people get annual check ups than visit doctors for respiratory conditions or high blood pressure, and the price tag for yearly physicals closes in on the $8.1 billion spent on breast cancer care.

The Truth about the Politics of National Health Reform

For the past year, progressives have begun to talk about health care reform as if it is inevitable. Listen to the Democratic Party’s presidential candidates, and it seems just a question of what form the health care revolution will take, how quickly it will happen, and how we’ll finance it. After all, the polls show that the majority of taxpayers, employers and even most doctors want to see a major change.  Moreover, health care research shows that if we cut the waste in our system, we could fund universal coverage. What, then, is stopping us?

As regular readers know, I recently attended a Massachusetts Medical Society Leadership Forum where what I heard about the Massachusetts plan made my heart sink. While everyone in Massachusetts wants health care reform, no one wants to pay for it. Those who are receiving state subsidies to buy insurance are enthusiastic. But uninsured citizens earning more than 300% of the poverty level are expected to purchase their own insurance. The state hoped that 228,000 of its uninsured citizens would sign up; as of last month, just 15,000 had enrolled. Many have decided that they would rather pay the penalty than buy health insurance.

At the forum, Robert Blendon, professor of health policy and political analysis at Harvard’s Kennedy School of Government, talked about what Massachusetts’ experience might mean for the national health care debate: “Massachusetts is the canary in the coal mine,” Blendon, who is also a professor at Harvard’s School of Public Health, declared bluntly. “If it’s not breathing in 2009, people won’t go in that mine.”  If the Massachusetts plan unravels, he suggested, Washington’s politicians will say “If they can’t do it in a liberal state like Massachusetts, how can we do it here?” 

I’m not writing Massachusetts off. The state’s leaders are behind the plan and they may be able to persuade the Commonwealth’s citizens to come on board. But it won’t be easy. 

In the meantime, this week I decided to ask Blendon some follow-up questions: Just what would it take, politically, to achieve national health care reform sometime in the next two to four years?  How many seats would reformers have to capture in Congress?  Is this likely?   Some observers say that if a reform-minded president hopes to succeed, he or she will have to ram a plan through Congress sometime in 2009. But health care is complicated; wouldn’t it make more sense for a new administration to take its time and explain what it is doing to the public, while trying to create a sustainable, affordable, high quality health care system?

Finally, what are the biggest barriers to reform?  If major change proves impossible, what more modest back-up plans should a new president have in mind? What other health care legislation could he or she hope to pass?

Online Doctors, Privacy, and the Almighty Dollar

Last month a slew of media outlets caught wind of Jay Parkinson, a 31 year old Brooklyn-based M.D. who provides care for his patients through the Internet. Here’s how it works: you get an initial in-person consultation at your home or office. After that, you can ask Parkinson questions online through instant message or video chat; e-mail him digital images of minor wounds, rashes, etc., that he can then diagnose; have him help contact, call ahead, and inform specialists when you need their help; and generally fulfill most basic medical consultation functions online.

Parkinson’s work raises a lot of questions, but first among them may be this: how come my doctor isn’t utilizing virtual communication to its fullest potential?

Part of doctors’ technophobia stems from their lack of incentives to engage with the virtual world: they’re not reimbursed for virtual consultations that may be deemed “self-management support activities,” or good old fashioned advice about do-it-yourself care. As little as eight percent of patients communicate with their doctors via e-mail—a shame, considering in the latest issue of JAMA, Tom Delbanco from Harvard Medical School estimated that 50 percent of visits to the physician are unnecessary and could probably be dealt with online.

But there are other reasons why doctors are reluctant to take their practice online. For most doctors, communicating sensitive patient information without special, government-approved secure platforms is illegal under the Health Insurance Portability and Accountability Act (HIPAA). HIPAA, originally passed in 1996, was revised in 2002 by the Bush Administration to incorporate a privacy rule that came into effect in 2003. The privacy rule regulates the use and disclosure of private health information (PHI), which is information about “health status, provision of health care, or payment for health care that can be linked to an individual.” It’s this privacy rule that makes so many doctors computer-shy.

Human Growth Hormone and The Business of Immortality

Last week, James Forsythe, a prominent doctor in Reno, Nevada was acquitted by a federal jury after going to trial on allegations that he trafficked in human growth hormone (HGH). The decision came as a relief to the American Academy of Anti-Aging Medicine (A4M), because among other allegations, the doctor was accused of selling HGH as an anti-aging treatment, which is illegal in the U.S. A4M has a history of pushing for HGH-driven anti-aging treatments.

So what’s so special about HGH when it comes to aging? Beginning in your 40s, the pituitary gland slowly reduces the amount of hormone it produces, a fact that some feel is both responsible for the frailty of age and reversible through the introduction of synthetic growth hormones.

But there is little, if any, reliable scientific evidence about the anti-aging benefits of HGH. In fact, there are no double-blind placebo-controlled studies for most of the anti-aging miracle cures out there. Yet we do know for a fact that HGH can increase the risk of cancer—not to mention edema (retention of fluids), arthralgia (joint pain), carpal tunnel syndrome, diabetes, and gynecomastia (enlarged mammary glands in males).  Oh, and it might actually shorten life.

When the Government Does What Drug-Makers Won’t Do

Today, Bloomberg News reported that “Deadly Staph Germs May Be Cured by Old, $1-a-Day Antibiotics.” It turns out that generic, World War II-era antibiotics are becoming “the newest weapon of choice in the fight against deadly, drug-resistant staph germs.”

Physicians have discovered that drugs costing less than $1 a day can be very effective when treating methicillin-resistant Staphylococcus aureus, known as MRSA. The bacteria, once found only in hospitals and nursing homes, recently made news by showing up in schools and gyms. Last month, MRSA was linked to the deaths of a student in New York and one in Virginia.  Annually, more than 18,000 Americans are killed by MRSA.

The physicians who mounted the studies of the older drugs were funded by the federal government. Meanwhile, in the for-profit private sector, Bloomberg observes, “drug-makers are spending hundreds of millions developing medicines that cost more than $100 a day to treat advanced cases.”

But physicians know the older, cheaper drugs work. “We have used these older drugs with success for years,'' says Gregory Moran, one of the study leaders. He is a professor of emergency medicine at the Olive View-UCLA Medical Center in Sylmar, California, affiliated with the University of California at Los Angeles.

The Genetic Effects of Loneliness

In September, a UCLA study took the long-recognized connection between loneliness and poor health to a new level by uncovering the genetic consequences of loneliness (see the full text of the study here). Its results are compelling, both on their own and as an opening salvo in medicine’s new campaign to understand how perception, feelings, and interaction with others determines health. 

Measuring loneliness (referred to in the study as “social isolation”) through the UCLA loneliness scale, researchers found that “feelings of social isolation are linked to alterations in the activity of genes that drive inflammation, the first response of the immune system.” At the same time, “key gene sets were under-expressed”—in other words, were not as functional as you'd expect them to be--in lonely individuals, “including those involved in antiviral responses and antibody production.”

In other words, loneliness fundamentally alters our immune system. As one author put it, “…the biological impact of social isolation reaches down into some of our most basic internal processes …the activity of our genes; changes in immune cell gene expression  in [ways that are] specifically linked to the subjective experience of social distance.” This is important: it’s feeling alone that matters. 

What Rudy--and Most Americans--Still Don’t Understand about Prostate Cancer

Presidential candidate Rudy Giuliani recently made the mistake of trying to turn his brush with prostate cancer into a campaign issue: “I had prostate cancer, five, six years ago. My chance of surviving prostate cancer, and thank God I was cured of it, in the United States, [is] 82 percent. My chances of surviving prostate cancer in England, [is] only 44 percent under socialized medicine,” Giuliani declared.

Rudy, of course, was wrong.

Merrill Goozner has done the best job that I’ve see of cutting through to the truth of the matter. In a Nov. 2  post titled “Columnists Miss Chance to Educate on PSA Testing,” he points out that “Paul Krugman's column in the New York Times and Eugene Robinson's column in the Washington Post justifiably attack Rudy Giuliani's misuse of prostate cancer stats, all but accusing him of lying.

Doc Treats Sheiks, Sells Cars, Hoping to Make Med School Affordable

Today, I received this e-mail from Dr. Terry Bennett of Rochester, New Hampshire, commenting on my post about the cost of Medical School ("Why Aren't More Students Applying To Medical School?"). Bennett, who is an alumni of Harvard Medical School, also sent a marvelous story from The Boston Globe (below)

First, Bennett's comment: "Harvard Medical School, with the  biggest Endowment in the world, refused and still refuses to spend the money on tuition reduction, preferring to make greedy rich white guys richer," says Bennett, referring to the fact that in 2003 two of the money managers at the Harvard Management Company were paid more than $35 million."The managers of the endowment took home enough money last year to send more than 4,000 students to Harvard for a year," Bennett said at the time. "The official Harvard 'greed is good' mindset, is the mind set all over the USA, essentially.

"On Day one, at Harvard [Medical School] almost every first year student polled 'wants to do some good in the world, and take care of people.' By day 365 the same kid wants to be a Dermatologist. The difference? $50,000 in student debt. Average total debt upon graduation $300,000... The tuition is just the beginning.

"We need to cure greed if we are to restore altruists' interest in becoming a doctor. Sadly, Greed is hard as hell to cure....Who would know better than I, who tried so very hard?? --Terry Bennett MD MPH"

How did Bennett try?  He attached this story from The Boston Globe:   

Why Aren’t More Students Applying To Medical School?

Did you know that there are only two applicants for every place in U.S. medical schools?

In Canada, surprisingly, close to four students apply for each opening. The training in the two countries is very similar; indeed, the Association of American Medical Colleges (AAMC) accredits medical schools in both countries.  And, in the U.S., at the high-end, physicians  can hope to earn far more than Canadian doctors.

Why then do so few Americans apply to medical school?

The answer is that we have priced a medical education well beyond the reach of most middle-class students.  In 2004, tuition and fees at a public medical school averaged $16,153. Students who attended a private school paid $32,588 according to a 2005 study published in The New England Journal of Medicine. 

The author, Dr. Gail Morrison, Vice Dean for Education at University of Pennsylvania School of Medicine, tacks on $20,000 to $25,000 a year for living expenses, books and equipment to calculate that the total cost of four years of medical education comes to a heady $140,000 for public schools and $225,000 for private schools.  I’d add that, in many American cities, students would be hard-pressed to cover rent, food, clothing, utilities and transportation for $20,000 a year—let alone books and equipment.

This helps explain why 60 percent of all medical students come from the wealthiest one-fifth of all U.S. families. Another 20 percent come from families lucky enough to be on the fourth step of a five step ladder.

We Need to Begin A Conversation About “Cost Effectiveness”

As any policy-maker knows, catering to public opinion, ensuring the public interest, and managing costs can seem an impossible task--especially when what the public thinks it wants is at loggerheads with what it needs. But in the case of health care, there may be an opportunity to do all three at once according to a proposal in the September/October Health Affairs.

The proposal argues for cost-effectiveness analysis (CEA) “to set priorities for Medicare coverage of new or costly interventions” through a citizens’ council made up of “a cross-section of users” who can provide leadership with “well-considered social-value judgments.” This citizens’ council model is borrowed from the UK, where a group of 30 men and women advise the National Institute for Health and Clinical Excellence (NICE) on behalf of the public.

The British experience shows that there are likely to be practical complications with implementing a citizens’ council, but it’s still an idea that’s on the right track. We need to turn “cost-effectiveness” from a bad word into a public interest issue in the US.

The Ten Most Overused Medical Tests and Treatments

I often write about how difficult it is to evaluate the quality of health care.  There is no Consumer Reports (CR) for healthcare, I argue, because while CR can rate mid-priced refrigerators briskly and clearly, in a way that makes comparisons easy, it is often all but impossible—even for a physician—to be positive of the relative benefits of a great many medical treatments. 

But if it’s hard to sort out the “best” healthcare, it may be easier to spot both negligent and unnecessary care.  As a hospital CEO once told me, “Our patients know whether they like the food, and the views, and whether the nurses are pleasant. They really have no way of knowing whether they are getting very good care or mediocre care . . . Though,” he added, “they are more likely to be able to tell if they are getting bad care.”

With that thought in mind, it might be worth taking a look at Consumer Report’s list of the 10 most overused medical tests and treatments. Thanks to  Gary Schwitzer of the University of Minnesota’s  School of Journalism and Mass Communication for calling attention to this list on his always interesting Schwitzer Health News Blog. As Schwitzer points out, “You can quibble with the list, but you can't help but commend CR for raising public awareness about the medical arms race.  And this list is just part of a broader special section on overspending on overtreatment.”