Checklists Update--Administration Stops Program

Today (Sunday, Dec. 30) the New York Times published a shocking op-ed by Dr. Atul Gawande revealing that a U.S. government agency has stopped an enormously successful "checklist" program that was being used to reduce infections in intensive care units at Johns Hopkins and throughout the state of Michigan. (To see my original piece  on checklists, scroll down to my Dec. 14 post below.)

Below, an excerpt from today's op-ed:

" In Bethesda, Md., in a squat building off a suburban parkway, sits a small federal agency called the Office for Human Research Protections. Its aim is to protect people. But lately you have to wonder. Consider this recent case.

"A year ago, researchers at Johns Hopkins University published the results of a program that instituted in nearly every intensive care unit in Michigan a simple five-step checklist designed to prevent certain hospital infections. . .

"The results were stunning. . . . Over 18 months, the program saved more than 1,500 lives and nearly $200 million

"Yet this past month, the Office for Human Research Protections shut the program down. . .

Happy Holidays!

I hope everyone has a wonderful holiday.  Health Beat will be taking a vacation—but we’ll be back January 2. And sometime early in the New Year, we’ll have a new design—with the larger typeface that some of you have asked for.  Be well.

Underreported Humanitarian Crises of 2007

Thanks to Merrill Goozner at GoozNews for calling attention to Doctors Without Borders’  list of the ten most underreported humanitarian stories of 2007.

The global humanitarian physician’s group (Doctors Without Borders/Medicine Sans Frontieres, or MSF) zeroes in on ten horrifying examples of suffering so extreme that it is difficult imagine. At this time of year, it seems appropriate to try to take in at least two examples.

The first story below focuses on the tuberculosis epidemic that, as the New York Times explained last year, “is outrunning us. In the last few months, 53 patients in the South African province of KwaZulu-Natal were found to have a form of the disease resistant to enough existing drugs that it is virtually incurable. All but one of those patients has died. Airborne and deadly, extensively drug-resistant TB is a nightmare disease. It has been found worldwide, including in the United States. . .

“The development of antibiotics had allowed wealthy nations to dismiss TB as a disease of the past. But H.I.V and AIDS have changed that calculus. In Africa, active TB cases are rising by 4 percent a year, largely because H.I.V. activates latent TB infection. TB is the leading cause of AIDS-related deaths. Every patient tested in the KwaZulu-Natal study was H.I.V.-positive and more than a quarter of those who died were taking antiretroviral therapy.

“African health officials gathered in South Africa last week to discuss extreme tuberculosis, but they are hobbled by the world’s indifference . . .

“Money for clinical trials would speed things. But donors have always slighted tuberculosis. According to a new report by Results International, an advocacy group, the World Bank spent only $3.5 million directly on TB in Africa in 2005. The Global Fund to Fight AIDS Tuberculosis and Malaria and the Bill and Melinda Gates Foundation are big donors, but much more is needed. Stinginess created this problem. Generosity is needed to fix it.”

Open Question: Should Physicians Be Involved in Lethal Injection?

In the newest issue of JAMA, two authors affiliated with the AMA offer their opinions on physicians’ role in implementing the death penalty via lethal injection. Hint: they don’t approve of it.

The article says that unlike other methods of execution, lethal injection “has elements of medical practice: insertion of intravenous lines, intravenous injection of medicinal drugs, and monitoring vital signs.” Small wonder then, that 35 of the 38 states that allow the death penalty either require or permit physician participation in executions.

Typically the identity of physicians who participate in executions is held confidential by state authorities. Even if they are made known, licensing boards in death penalty states have trouble taking any action against physicians who participate in executions. Since the boards deal with illegal activities, they can’t crack down on physicians who participate in executions that are legal.

But medical societies have more wiggle room. AMA prohibits involvement of physicians in executions, saying that it goes against the physician’s role as a healer. As the authors put it, “any form of participation in causing death by lethal injection is unethical because it violates the physician’s role, thereby undermining trust….the penal system, not the medical profession, is responsible for finding a way to perform executions.”

Obviously this issue has a certain degree of timeliness, given the Supreme Court’s recent agreement to hear challenges to lethal injection on the grounds that the process often gets so mucked up that it constitutes cruel and unusual punishment. But I think the JAMA piece is right in addressing it as a big-picture best practices question. This is primarily a moral question.

And it’s a tough one, even for physicians who might support capital punishment in the criminal justice system. Just because they believe that murderers should die, it doesn’t follow that they feel criminals do or do not deserve a demise that is as painless as possible. Supporting capital punishment and consenting to having a hand in it are two very different things.

So imagine you’re a doctor and the state has asked you to preside over an execution that will go on with or without a physician present. What’s your medical duty—to try to ensure that things go smoothly and spare the inmate unnecessary pain, or abstain from attending because your presence would mean you were participating in taking a life? Which choice is truer to the physician’s duty to be a healer?

Taxes: Weight Watchers for the Health Care System

A few days ago San Francisco Mayor Gavin Newsom proposed adding a surcharge on soft drinks with high-fructose corn syrup as part of a campaign to combat obesity.

Newsom’s “soda tax” is just the latest development in a series of metropolitan initiatives aimed at promoting healthier living. New York, which pioneered smoking and trans fat bans, has been the most gung-ho city and similar bans now have been passed, or are being considered, by cities across the nation—and the world. 

Efforts like the soda tax are often derided as unnecessary big government intrusions, especially for something like corn syrup (or trans fat) that doesn’t hurt bystanders the way second-hand smoke does. Those who eat or drink poorly only hurt themselves; and the right to self-destruct is a right the government should respect (or at least this is what some say).

But here’s the problem: the cumulative effect of saying that obesity isn’t my problem is to make it everyone’s problem. Newsom’s spokesman, Nathan Ballard told the New York Times that “there’s a well-established nexus between obesity, which is caused by high-fructose corn syrup, and the increased health care costs for the city.” According to a 2004 study in the Annual Review of Public Health, obesity is responsible for between 5 percent and 7 percent of total annual medical expenditures in the United States. Every year excess weight costs our health care system more than $90 billion. Even employers shoulder the burden of obesity: overweight workers require as much a $2,500 extra in health care costs, adding up to almost $300,000 in medical expenses for a 1,000 person firm.

The reason why obesity costs so much is obvious. Individuals who are carrying too much weight are at an increased risk of hypertension, osteoarthritis, high cholesterol, type 2 diabetes, heart disease, stroke, gallbladder disease, respiratory problems, and cancer. And it’s only getting worse. A RAND study from earlier this year found that from 2000 to 2005 the obesity rate in the U.S. (, i.e. the number of people with a body mass index of 30 or above,) increased by 24 percent. Meanwhile the number of people with a BMI over 40 grew by 50 percent, and the number of people with a BMI over 50 grew 75 percent.

How Soon Can We Expect National Health Reform?

On this blog, we have debated how soon Americans will be ready for national health reform.  Many observers believe that we’ll only get reform when more people are uninsured—specifically when more middle-class and  upper-middle-class families find themselves “going naked.”

The chart below comes from a new Commonwealth Fund Report which shows that while two-thirds of low-income adults (earning less than 200 percent of the federal poverty threshold) were uninsured or underinsured in 2006, just 17 percent of those earning more than 200 percent of the federal poverty level (FPL) were either underinsured or uninsured at some point during the year.

“Underinsured” is defined as someone who finds himself spending 10 percent or more of his income on out-of-pocket medical expenses. (For those earning less than 200 percent of FPL, the number is 5 percent.)

The report observes that employers are continuing to back away from offering health benefits:  “Between 2000 and 2005, the proportion of workers receiving employer-provided health insurance declined from 74.2 percent to 70.5 percent,” and again “middle- and lower-wage workers,” suffered most, with “the largest decreases” hitting this group.

Are Americans Working Health Care into the Ground?

We Americans are proud of our work ethic. We work longer hours, and more productively, than any other nation. Our industriousness has long been cited as a source of strength of our economy—but it just might be a source of some of our health care woes as well. 

According to a just-released study from Wake Forest University, professional flexibility is an important contributor to better health. Employees at all levels who have, or feel they have, more job flexibility (e.g. the ability to work from home, choose their hours, etc.) engage in healthier behavior than those that don’t. The study found that employees with flexible schedules exercised more, attended more employer-sponsored health classes, were more likely to describe themselves as living a healthy lifestyle, and reported getting more sleep. When the researchers checked in a year later, they found that as job flexibility improved, so did healthy habits: more flexibility meant more sleep, more health classes, and a healthier lifestyle.

This study deserves attention. Changing behavior is the single most powerful way to prevent health problems. As experts from the Robert Wood Johnson Foundation noted in a Health Affairs article earlier this year, “behavioral issues represent the greatest single domain of influence on the health of the U.S. population,” with 40 percent of early deaths in the U.S. due to behavioral patterns. Anything that promotes health behavior needs to be seriously considered as a strategy for making America healthier—and by extension, health care costs lower. 

Obviously, somehow ensuring that everyone in America had more flexible hours wouldn’t cut early deaths by 40 percent. And there’s no guarantee that more flexible hours will translate into better sleep, more exercise, or more education on a national scale. Any movement for universal job flexibility would have to be coupled with a concerted effort to translate free time into healthy time.

But this study gets us thinking about behavior as more than just the usual spate of no-nos like smoking or eating poorly. Work is behavior. Work is relevant to health—more so even, than the Wake Forest University study suggests. There’s an argument to be made that more job flexibility can translate into a shift away from medication in two big arenas: childhood disorders and depression.

Donating an Organ: Should It Be A Gift?

A story in yesterday’s New York Times Magazine raised some very thorny questions about organ transplants. I spent the afternoon reading more about transplants; by evening I had stumbled onto what seems to me at least a partial solution.

The NYT piece tells the story of Sally Satel, a 49-year-old psychiatrist in need of a kidney transplant. In 2004, her kidneys suddenly, quite inexplicably, began to fail. (The cause may have been a medication she had taken in her twenties.)  She had no living relatives except a couple of cousins whom she rarely saw. A close friend came forward, was tested, found that her blood was a match, volunteered to donate a kidney--and then reneged. (It turns out that when she went to chorus practice one evening, “a fellow alto” talked her out of it. The fellow-alto was, of all things, an organ transplant specialist. Satel was enraged: “a transplant surgeon should know how hard it is to get a donor.”)

A second friend volunteered, and again proved a match. But then she, too, got cold feet-- though she didn’t tell Satel right away.

Finally, a 62-year-old stranger in Canada saw Satel’s message on an organ match website, called and offered to help her.  He was the right blood type, he seemed “steady” and “honest,” and after a few weeks of phone calls and e-mails, they set a date to do the operations in early January. Then, just before Thanksgiving, he went dark. “Everything turned to radio silence as my e-mail and phone messages went unanswered,” Satel recalls. When her transplant coordinator contacted him, he waffled. He wasn’t sure he would be able to make it in January; he was too heavily involved in a political campaign…

“I was astonished at the Canadian’s . . . what? Negligence, cowardice, rudeness?” Satel writes. “It was a sickening roller-coaster ride: hope yielding to helpless frustration, gratitude giving way to fury. How dare he reduce me to groveling and dependence? Yet I assume he intended no such thing. I think the Canadian was actually quite devoted to the idea of giving a kidney — just not necessarily now or to me.”

By now Satel is desperate. She realizes that her only alternative is dialysis “three days a week, for four debilitating hours at a time, I would be tethered to a blood-cleansing machine… I had an especially morbid dread of dialysis,” Satel admits.  She was haunted by what she had read about “the playwright Neil Simon [who] received a kidney from his longtime publicist in 2004 . . .but before that he endured 18 wretched months on dialysis, suffering cramps and vomiting spells that kept him largely confined to his house. His memory deteriorated, and he hated the time away from his writing. Shortly before his donor came forward (unsolicited, it should be noted), Simon’s doctors said he might have to start spending more time on dialysis. If that were necessary, he said, he had decided, ‘I didn’t want to live my life anymore.’ Neither, I thought, would I.”

Pilots Use Checklists. Doctors Don’t. Why Not?

This is a question Dr. Atul Gawande explores in the December 10 issue of The New Yorker. “The Checklist” is a shocking story, it’s an important story—and it’s also very long. I, of course, would be the last person on earth to criticize someone for “writing long” but it occurs to me that many of HealthBeat’s readers may not have the time to peruse the full nine-page story, so I decided to offer a capsule summary here. (To read the story in its entirety, click here).

Gawande is the author of one of my favorite healthcare books, Complications: A Surgeon’s Notes on an Imperfect Science, and he writes wonderfully well. This piece begins with a riveting tale of a three-year-old who falls into in icy fishpond in a small Austrian town in the Alps. “She is lost beneath the surface for 30 minutes before her parents find her on the bottom of the pond and pull her up.” By then “she has a body temperature of 68 degrees—and no pulse.” A helicopter takes her to a near-by hospital. 
There a surgical team puts her on a heart-lung bypass machine. She now has been lifeless for an hour and a half. Gradually, the machine begins to work. After six hours, her core temperature reaches 98.6 degrees, but she is hardly out of the woods. Her lungs are too badly damaged to function, so the surgeons use a power saw to open her chest down the middle and sew lines to and from an artificial lung system into her aorta and beating heart. “Over the next two days, all of her organs recover except her brain. When a CT scan shows global brain swelling, the team drills a hole into her skull, threads in a probe to monitor cerebral pressure, and adjusts fluids and medications to keep her stable. “

Slowly, over two weeks, she comes back to life. “Her right leg and left arm [are] partially paralyzed.  Her speech [is] thick and slurry.  But by age five, after extensive outpatient therapy, she has recovered her faculties completely. She [is] like any little girl again.” 

“What makes her recovery astounding,” Gawande writes, is “the idea that a group of people in an ordinary hospital could do something so enormously complex. To save this one child, scores of people had to carry out thousands of step correctly; placing the heart-pump tubing into her without letting in air bubbles, maintaining the sterility of her lines, her open chest, the burr hole in her skull; keeping a temperamental battery of machines up and running” all the while “orchestrating each of these steps in the right sequence, with nothing dropped . . .”

This, Gawande says, is what happens in intensive care units, every day of the year, all across the country. “Intensive care medicine has become the art of managing extreme complexity—and a test of whether such complexity can, in fact, be humanly mastered.”

Complaints about Medicare Advantage Mount...While Congress Contemplates Slashing Fees Traditional Medicare Pays Docs

Recently I argued that eliminating the private insurance industry would not suddenly make health care affordable. But this is no reason to gratuitously overpay private insurers to provide health care to Medicare patients—while simultaneously planning to slash the fees that Medicare pays physicians.

Begin with the insurers. When Congress created Medicare Advantage, the program that allows private insurers to offer Medicare to seniors, it agreed to pay for-profit insurers about 12 percent more per patient than traditional Medicare would spend if it were covering those patients directly.  Add up those extra payments and they amount to a $16-billion-a-year subsidy for the health insurance industry.

Why the sweetener?  Lobbyists argued that the government would have to pay more to persuade for-profit insurers to join the Advantage program.  Moreover, they promised that the insurers would use the $16 billion to offer patients extra benefits like acupuncture and eye exams that they would not receive under traditional Medicare.  And Congress agreed. Now, think about this for a minute: legislators agreed to use our tax dollars to help for-profit insurers draw customers away from a government program that most people liked—and that cost taxpayers less.  This is not about saving money by transferring Medicare to the supposedly more efficient private sector. This is about the conservative agenda: some politicians are determined to try to outsource government to for-profit corporations.

Predictably, private insurers structured their plans to siphon off the healthiest seniors.  In New York City, for example, Oxford included free memberships to some pretty posh gyms as part of the package. They called it the “Silver Sneakers” program. Unfortunately, a year after seniors signed up they discovered that the number of gyms involved in the program had suddenly shrunk. The options that remained weren’t nearly as tony, and most were no longer located in upper-middle-class residential neighborhoods. Is this “bait-and-switch”? You decide.

Health Wonk Review Is Up

This week David Harlow is hosting Health Wonk Review. For a summary of the best health care posts of the last two weeks, go to HealthBlawg.

The Drug War versus Health Care

Yesterday President Bush gave a speech on the success of his drug policies in celebration of a new report showing that teen drug use has continued a decline that began in 1997. But it is not entirely clear that there is much cause for celebration: use of some of the most hardcore stuff—such as cocaine, crack, LSD, and heroin—has held steady over the past five years or so. True, recently the use of marijuana, amphetamines, and methamphetamines has dropped, but that’s hardly reason to declare victory in the war on drugs.

Like any good president, Bush wants to take credit for good news. But as the lack of progress in the battle against heroin and crack suggests, the U.S. is on the wrong track when it comes to drugs. Our institutional bias is still to see drug use and drug control as criminal justice issues when we should really be thinking about them as public health concerns.

Just take a look at history. According to a Health Affairs article from earlier this year, since 1987 public and private investment in substance abuse (SA) treatment has not kept pace with other health spending. From 1987 to 2003, the average annual total growth rate for SA treatment was 4.8 percent, while U.S. health care spending grew by 8.0 percent each year. Because of this mismatched growth rate, SA spending fell as a share of all health spending from 2.1 percent in 1986 to 1.3 percent in 2003.

Compare this drop in treatment spending to the increase in drug arrests: according to the Bureau of Justice Statistics, in 1987 drug arrests were 7.4 percent of all arrests reported to the FBI; by 2005, drug arrests had risen to 13.1 percent of all arrests. Our spending on SA treatment and the volume of drug arrests are moving in opposite directions. And for all the political pageantry surrounding yesterday’s report, President Bush’s FY 2008 budget calls for cutting $158.7 million from the Substance Abuse and Mental Health Services Administration (SAMHSA) budget and $278.9 million from the Safe and Drug-Free Schools and Communities (SDFS) program. 

Immigrants Exploit Our Health Care System…Right?

There’s no easier punching bag in politics today than undocumented immigrants. They can be blamed for any number of problems—including high health care costs. The Federation for American Immigration Reform (FAIR), for example, insists that “the costs of medical care for immigrants are staggering.”

But a handful of hot-off-the-press reports tell a different story. A just released Congressional Budget Office (CBO) study concludes that while immigrants are indeed “more likely [than American citizens] to rely on emergency rooms or public clinics for health care” the cost of caring for immigrants is much less than alarmists would have you believe.

This conclusion clashes with the widespread conception that emergency rooms around the nation are filled to the brim with Mexicans—all on the dime of the American taxpayer. In fact, a November UCLA study showed that “undocumented immigrants from Mexico and other Latin American countries are 50 percent less likely than U.S.-born Latinos to use hospital emergency rooms in California,” the state that incurs the most undocumented immigration-related costs. (The lower rate of hospital use is due to the fact that undocumented immigrants tend to be young and healthy. After all, border-crossing is a rough experience).

Of course, it’s not the rate of health care use that has people worried—it’s the cost of use. But a 2006 RAND study concluded that in 2000, health care for undocumented immigrants between 18 and 64 years old cost taxpayers about $11 per household—roughly the price of a cheeseburger in Manhattan.

Part of the reason the price tag is so low is that our health care system does only the bare minimum for undocumented immigrants. The CBO reports that 1986 Medicaid reforms stipulated that immigrants could receive emergency Medicaid for must-have-care situations like childbirth. But “emergency Medicaid covers only those services that are necessary to stabilize a patient; any other services delivered after a patient is stabilized are not covered.” Undocumented immigrants are only assured enough health care to make sure they don’t die; so the costs of emergency Medicaid are very low.

Reform under the Radar: What Medicare Needs to Do to Control Costs

Below, a very welcome contribution from Shannon Brownlee,  author of Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer (2007),  an outstanding report on why ‘more care’ often is not ‘better care’.   An award-winning journalist and Schwartz Senior Fellow at the New America Foundation, Brownlee has written extensively about health care for the many publications including the Atlantic Monthly, the New York Times, and the Washington Post.

As I’ve suggested in the past, Medicare reform could be a stepping stone to national health reform. Ideally, we would do both simultaneously. In this post, Brownlee puts her finger on what is wrong with the way Medicare has traditionally tried to cut costs.  In future HealthBeat posts, we’ll talk more about specific proposals for cutting Medicare waste.

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While Barack, Hillary, and Paul Krugman slug it out over the individual mandate, it’s worth pausing for a second to wonder why nobody is saying much about controlling health care costs. Yes, covering everybody is the right thing to do, it’s the moral thing to do, but it isn’t the only thing to do. Theoretically, it shouldn’t even be the hardest thing to do, because at its core, covering everybody is mostly a matter of being willing to come up with the money.  In reality, of course, coming up with the money is a political nightmare.

Controlling costs, on the other hand, is a much deeper problem, but oddly enough it may be easier to achieve politically at the federal level than universal coverage. That’s because cost containment can begin with Medicare, which has been instituting cost control measures under the radar for years. Its efforts have resulted in a lot of bitching and moaning from the hospital industry and doctors, but not a lot of political fallout.

So why aren’t Medicare’s cost control measures working? Because CMS has focused most of its efforts to limit spending on controlling prices. This strategy arises out of the mistaken belief that if they could just rein in the price per unit of care, the price of each CT scan and each office visit, they could control spending overall. This would be a dandy strategy in any other industry, but in health care it hasn’t worked out. And it hasn’t worked out because in health care, the real driver of cost is volume. Costs go up when the amount of care doctors and hospitals deliver to each patient goes up. And because the amount of care delivered doesn’t have all that much to do with the amount of care that patients actually need, whenever Medicare slashes the price it will pay, hospitals and individual physicians can always find ways to deliver more stuff in order to maintain their revenue stream.   

The Academic Buzz around Health Care

Being a young whippersnapper, it never occurred to me that health care policy was a relatively new field of study within our universities. But when Health Beat reader Bradley Flansbaum passed along the  Reuters story below to Maggie (original here)  and she passed it on to me, I gained a new perspective on the issue. It turns out that until very recently, health care used to just mean medicine. But today, thinking about health care demands thinking about  a lot of different things, like public policy, public administration, economics, politics, and even sociology.

This mixed bag is reflected in the diverse academic offerings at colleges and universities—as well as the swell of students interested in them. The Reuters story below suggests that there are three main motivations for the increased student interest: fascination, idealism, and profit. That sounds about right. You can either be genuinely interested in the complexities of health care or the politics surrounding it; want to fix the system for the greater good; or want to learn as much as you can about the system to better navigate it for GlaxoSmithKline.

There’s obviously a lot of good to be had from generations growing up understanding more about our insanely complex and counter-productive health care system. Teaching college students about the system now might instill a long-term openness to reform and improvement that wasn’t present in generations who never knew about health care until they got sick.

But I can’t help but wonder about the faddishness of it all. After all, health care isn’t the only broken system that could use some attention. Consider the criminal justice system. Back in the day, law and order meant being a lawyer or a cop. But today there are criminology and criminal justice programs around the world that focus on issues like incarceration, community policing, cost, risk management, and more. Yet the buzz surrounding these issues hasn’t been comparable to the much louder debate about health care—even though one out of 32 Americans is currently in the corrections system and a black male is more likely to have served time in jail than have a college degree. This too is a crisis.

Update on Mandates

Today the Wall Street Journal has been running a poll asking readers how they feel about mandates requiring that everyone sign up for health insurance. Asking “What should the federal government do about the uninsured?” the Journal gives readers three options:

(1) Require everyone to have insurance coverage, but keep private insurance.

(2) Adopt a single-payer, government-funded system.

(3) The government shouldn’t require everyone to have health care.

Late this afternoon, 347 people had responded, with 40 percent favoring mandates, 31 percent picking single-payer, and 29 percent saying the government should keep its sticky mitts off our free-market health care system.

Okay, this a very small poll, and it’s not random. But that is precisely what I find interesting.

I was surprised that 40 percent of the Journal’s relatively affluent readers voted for mandates since some of them are healthy and wealthy enough that they could easily “self-insure” by saving enough money in a health savings account to cover all but catastrophic medical expenses and then buying a low-cost, high deductible policy. Premiums for high-deductible insurance are going to be significantly lower than the premiums for mandated policies designed to ensure that everyone has comprehensive coverage (i.e. benefits comparable to what Medicare offers, plus maternity and other coverage younger people need).

Nevertheless, 40 percent think it is fair to require that  everyone to pay into the pool while another 31 percent pick a single-payer system that would be funded by taxpayers.

Of course, 71 percent isn’t everyone. Consider the curmudgeon who sent in this comment: “Medical needs are endless...You are not your brother’s keeper no matter what the Bible or any other book written by superstitious savages says.”

That is why we need mandates. Trust me, this fellow is not going to sign up voluntarily.

Doctors Who Know Better—But Do the Wrong Thing

On Health Care Renewal , Dr. Roy Poses reports on a disturbing new study just published in The Annals of Internal Medicine contrasting physicians' attitudes toward professional norms with their self reports of whether they acted in conformity with these norms.

Poses does an excellent job of summarizing, so I’m re-posting his piece in full below:

“In brief, the authors developed a survey which asked physicians whether they agreed with various professional norms organized according to the 2002 ABIM/ ACP/ ESIM Physician Charter. They also asked them about whether they acted in conformity with these principles in terms of their recent actions, or in responses to scenarios. Physicians surveyed were primary care practitioners (family medicine, general internal medicine, and pediatrics), cardiologists, anesthesiologists, and general surgeons. The overall response rate was 52%.

“In general, large majorities of physicians agreed with the ethical norms. How often they reported acting in agreement with these norms varied. In particular, nearly all physicians reported treating patients honestly (less than 1% reported telling a patient's family member something untrue in the last 3 years, 3% reported withholding information from a patient or a family member.) However, although 96% agreed that "physicians should put the patient's welfare above the physician's financial interests," 24% would refer a patient to an imaging facility in which the physician was an investor, without revealing this conflict of interest.

“Some commentators suggested that external pressures may prevent physicians living up to the standards they themselves have endorsed. For example, physicians interviewed in a Washington Post article suggested that the current emphasis on patient satisfaction may conflict with the physician's ethical obligation to avoid wasting resources when a patient demands an unnecessary but not clearly harmful test. The Congressional Quarterly reported quoted the CEO of the Federation of State Medical Boards saying that physicians "were penned in by the American the health care system, fighting giant bureaucracies while fearing legal action if they make a mistake."

Health Care Spending: The Basics

 

JUST HOW MUCH DO PRIVATE INSURERS ADD TO THE NATION'S HEALTH CARE BILL?

As a nation, we are spending well over $2 trillion a year on health care. This includes: all of the money that you and I pay out-of pocket to cover co-pays, deductibles and drugs; the dollars that you and I (and our employers) fork over for private insurance; the money Medicare, Medicaid and SCHIP lay out to reimburse doctors, hospitals and patients; the billions taxpayers chip in to fund veterans’ health programs, public hospitals, school programs, and health insurance for government employees as well as the money private charities contribute to health care.

What exactly are we paying for? How much of that money is used to pay the CEOs of drug companies salaries that read like telephone numbers? How much do hospitals eat up?  How much is spent on insurance company ads? How much is used to provide healthcare for the poor?

I’ve decided to do a series of posts spelling out exactly where the money goes. Today, I’m going to start with private insurance.

Many people believe that if we just eliminated the private insurance industry, healthcare would become much more affordable. There is a general sense that the “administrative costs” of private insurance are siphoning off a sizable share of our health care dollars.

There is some truth to that: because we  have  multiple insurers—not to mention so many solo practitioners, small hospitals, clinics, and individuals filing for reimbursement—the paperwork is enormous. If we had only one big insurance company that used just one set of forms we could simplify the paperwork greatly. People who want a “single payer” system, with the government paying all of the bills,  point out that the savings would be enormous.

And we could cut costs even more if, instead of having tens of thousands of health care providers filing for separate reimbursements, doctors, hospitals and clinics joined together into, say, eight our ten large organizations like Kaiser Permanente, each with its own back office.  The doctors would be on salary, so rather than filing for payment for each service they performed, they would receive a monthly check for taking care of their patients, just as they do at Kaiser Permanent or the Mayo Clinic (where doctors are on salary).

In other words, it is not only a fragmented multi-payer insurance industry that generates so much paperwork; on the other side of the transaction a fractured network of separate providers adds to a mind-boggling stack of paper. Unlike most other developed countries, we have turned healthcare into a  cottage industry. This gives us lots of choices: we can select from a Chinese menu of insurance plans and proviers. But it also means higher administrative costs. In this post I would like to focus first on just on how much our huge private insurance industry is costing us. (In a later post, we’ll look at the price we pay for a fee-for-service system of independent providers.)

New CDC Report: The Nail in the Coffin for Health Care Myths

On Monday the CDC released a landmark, and in many ways devastating, report on health care in the U.S. The report contains a wealth of data that, while not surprising to some, should help silence the dwindling few who insist that America’s health care system is doing just fine. As a public service, I thought it’d be helpful to list some of the myths that the report demolishes (with some help from other sources as needed).

Myth: If people don’t have health insurance or get medical care, it’s because they don’t want it.

Reality: Actually, the big issue with access is cost. According to the CDC report, more than 40 million Americans—almost one in five Americans over the age of 18—have foregone one of the following in the past year because they couldn’t afford it: medical care, prescription medicines, mental health care, dental care, or eyeglasses.

It’s not that uninsured people don’t understand the value of coverage. Last year a study from the Urban Institute found that less than 3 percent of uninsured adults and children have never had insurance or report having no need for insurance. That same report also found that the high cost of coverage alone explained over 50 percent of those cases where people are uninsured 

And even when the uninsured cite job-related difficulties as the reason why they can’t access employer sponsored coverage, the problem isn’t just that they can’t get it through work—it’s also that they can’t afford individual policies. (Individual policies are much more expensive than group policies, and in many states private insurers can charge individuals astronomical premiums if individuals have any “pre-existing conditions.)  According to the Urban Institute, for 79 percent of adults and 74 percent of children who are uninsured because of job-related problems, the high cost of individual insurance is a major problem.

Myth: The American system relies mostly, if not exclusively, on private enterprise to support health care.

Reality: Yes and no. While the U.S. does have the biggest private sector share of health expenditures in the world, making up 55 percent of our funding, personal health care expenditures (i.e. spending on actual patient care) is mostly public. The CDC reports that in 2005 the federal government and state and local governments combined paid 45 percent of personal health care expenditures; private insurers only paid 36 percent, with 15 percent coming from out-of-pocket payments. So much for the libertarian utopia.

There’s also a bigger public sector coverage presence than many would like to admit. Though two-thirds of insurance policyholders have private coverage, a Census bureau report from earlier this year noted that more than one quarter of Americans (about 27 percent) are covered by government insurance. The American model is much more of a private-public mix than some pundits—and candidates—are willing to admit.

The FDA: What Happens When You Starve the Beast

In October, I talked to a source inside the FDA who suggested that the agency was having a hard time keeping up with work-flow.  I quoted him on this blog as explaining 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 added, 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.”

Yesterday the FDA Science Board dropped a bombshell in the form of a report which suggests that standards at the FDA haven’t just fallen—they’ve fallen off a cliff. The title of the report says it all: FDA: Science and Mission At Risk. The problem, according to the report: a lack of funding. The Coalition for a Stronger FDA,  co-chaired by the last three secretaries of Health and Human Services (the department that oversees the FDA), says the FDA needs a 15 percent boost in funding per year for the next five years. 

Here are just a few highlights from the report:

• “The Information Technology situation is problematic at best—and at worst it is dangerous.”
• “The FDA has substantial recruitment and retention issues”.
• “Critical data…including valuable clinical trial data...are sequestered in piles and piles of paper documents in large warehouses."
• “The FDA has an inadequate and ineffective program for scientist performance."
• "The FDA has inadequate funding for professional development to ensure that staff maintain scientific competence."

William Hubbard, a former FDA associate commissioner who supports the Coalition for a Stronger FDA, told ABC News that the report stands out because of the "intensity of the feelings" expressed by the subcommittee.

"These people were horrified by what they found," he added.

Healthcare IT Is Not a Done Deal—Even in Theory

In a previous post, I briefly mentioned how the U.S. Department of Health and Human Services has started developing regional networks of electronic health information. Eventually, these networks will merge into a “network of networks,” thus working toward a nationwide, compatible system of electronic health records by 2014.

Unfortunately this “network of networks” approach of regional heath information organizations (RHIOs) has some serious faults. And the alternative system currently favored by many, health record data banks, still poses a lot of unanswered questions.

According to an October report from the Information Technology and Innovation Foundation (ITIF), the major problem with RHIOs is coordination: “multiple, heterogeneous databases” require “the extensive use of middleware—that is, software used to interface between incompatible databases and data formats.” Otherwise it’s like trying to run Mac software on a PC. Other coordination challenges include accurate patient identification (is John Smith in the Bronx the same as John Q. Smith in Cleveland?) and ensuring comparable service quality—each network needs to be as fast and secure as its peers.

With all of these inefficiencies, the ITIF study notes that RHIOs don’t make a very compelling business case to the health care providers who are expected to implement and operate the networks. Most of the system’s savings go to patients (because they can expect better care) and insurers (because mistakes can be avoided) rather than hospitals and doctors, who incur all the costs of transitioning to a new IT platform—a fact of which they’re well aware. A 2006 JAMA study showed that health care providers are worried about IT transitions primarily because of start-up costs (installation, consultation, training, etc), ongoing costs (such as compliance with privacy laws—no small matter, given the ambiguity of HIPPA) and the potential loss of productivity as employees learn the new system.

In lieu of RHIOs, ITIF recommends health record data banks (HRDBs), a model that has gotten a lot of buzz over recent months—including its own bill in Congress last year.

The simplest way to explain HRDBs is via analogy: think of how you engage with a commercial bank account, and you’re on the right track. Just as you choose a bank from a competitive marketplace of financial institutions, so would you pick an HRDB provider from many vying for your business; just as you open a bank account, so would you start a medical record account; and just as you log in to access financial information, make transactions, and monitor your activity with a bank, so would the HRDB service let you sign in online to access to your medical history, test results, and so on.

Obama Says No One Should Be Forced to Sign up For Insurance; Edwards Says If You Don’t, He’ll Garnish Your Wages—Who is Right?

John Edwards' declaration that under his health reform proposal anyone who refuses to sign up for health insurance will be subject to having their wages garnished has led to a blogstorm of often confusing debates.  Under national health reform, should everyone be required to enroll? The Edwards and Clinton plans have mandates insisting that all Americans purchase insurance; the Obama plan has a mandate for children, but not for adults

New York Times columnist Paul Krugman stirred controversy Friday by defending Edwards, and criticizing Barack Obama: “Under Obama’s health care plan, healthy people could choose not to buy insurance—then sign up for it if they developed health problems later,” Krugman observed. “As a result, people who did the right thing and bought insurance when they were healthy would end up subsidizing those who didn’t sign up for insurance until or unless they needed medical care.”

On Sunday former FCC Commissioner Reed Hundt called Krugman out on TPM Cafe in a post headlined “Ease up, Dr. Krugman.” According to Hundt: “The very idea of government mandates directed to individuals evokes a command-and-control model that disturbs citizens who want to enjoy certain freedoms in choosing health care.” As of yesterday, Hundt’s post had drawn some 60 comments—some on point, others muddying the waters.

Meanwhile, at TNR Jonathan Cohn weighs in with a long discussion of just how many people Obama’s plan might leave uncovered—and suggests that one of Obama’s advisers has information showing that under Edwards’ plan, even more Americans would be left “going naked.”

Because the conversation in the blogosphere has become such a mix of good information, misinformation and false assumptions, I’ve decided to try to spell out, as clearly as possible, why we need a mandate. Very simply, it addresses a serious defect in our health care system:  under existing rules, you don’t have to buy insurance, but you can be priced out of the insurance system if you are sick.

After examining that problem--and looking at how requiring insurance solves it-- I’d like to answer a sensible question that observers like the Washington Monthly’s Kevin Drum have raised: Why force people to buy insurance? Why not just tax everyone, put the money in a pool similar to the Medicare Trust Fund, and use it to buy universal insurance?