What's New in...Germany?

Today, as the first in an ongoing series of updates on what's new in international health care, I want to take a look at recent reforms in Germany. As a whole, we Americans pay precious little attention to what’s going on in other countries unless the news involves war or David Beckham. I'm hoping to buck this trend a little.

The big story in German health care is Chancellor Angela Merkel's late 2006 reform that resulted in series of changes that, for the most part, were implemented in April of last year. Below, a look at these reforms; but first a little political background: Merkel heads up a "grand coalition" government, i.e. one where the largest political parties govern in collaboration due to inconclusive election results (a relatively common occurrence in parliamentary systems). In other words, social democrats and conservatives are in a constant tug-of-war. The new plan reflects this fact, juggling solidarity and competition in equal parts. And while this might sound like a good balance, virtually no one is satisfied with the compromise.

On to the big changes:

Mandatory Health Insurance: Many folks think that European health care means, by definition, universal public coverage. Not so. Germany has a public/private system, and before the April 2007 reform, public coverage was only compulsory for those within a certain income range (roughly speaking, working and middle class citizens). Higher-income and self-employed Germans, along with public servants, could opt-out of SHI by purchasing private insurance. They could also forgo insurance all together.

Due to this set-up, until recently some 200,000 Germans were uninsured—about 0.2 percent of the population. As of April '07, all Germans must purchase health insurance. In the past, private insurers (who traditionally offer plans with many bells and whistles) had the right to refuse coverage for high-risk individuals. Now, they must take all comers. In this way, the new German plan is like Hillary Clinton’s proposal for health care reform: insurers can no longer shun the sick but everyone must sign up—citizens cannot wait  until they are sick to enroll.

After 28 Years, a “Totally New Deal” for Healthcare and the Economy?

Two seasoned political strategists, Paul Begala, and Stan Greenberg, spoke at “Health Action 2008,” a conference that Families USA sponsored in Washington last week.  There, they argued that the U.S. may be on the threshold of what Begala, a political contributor on CNN’s “The Situation Room,” called “a totally new deal.”  Greenberg, chairman and CEO of Greenberg, Quinlan Rosner, went a little further: “It is very possible that the whole conservative complex crashes.”

In an interview later that afternoon, Greenberg explained what he meant: “I think this election is going to mark an extraordinary defeat for conservatives.” Greenberg isn’t talking about the number of Congressional seats that the conservatives may lose: he is not forecasting a sweep for Democrats that equals the LBJ landslide. Instead, he’s predicting something more fundamental: that the right wing of the Republican party will be shattered. “There may be a fragmentation on the conservative side that changes what’s possible after the election.”

For many who came of age in the 1980s and the 1990s, this must seem unimaginable. For the past 28 years, the U.S. government has been held captive by the conservatives. Ronald Reagan sowed the seeds and George W. Bush harvested the fruit of a political movement bent on deregulation and smaller government while consolidating and preserving the wealth of the country’s richest citizens.

At the beginning of Bill Clinton’s first term, it seemed that the nation might be ready for deep changes, in large part because we had entered a recession that was threatening not just blue collar but white collar workers.  Middle-class and upper-middle class employees were afraid that they were going to lose not only their jobs, but their health insurance.  But as that recession eased, Bill Clinton’s first major initiative went down in flames.  A health care reform plan that would have signaled the beginning of progressive economic reform failed, in  part because Americans were no longer as anxious as they had been when Clinton captured the White House.  (Ezra Klein recently did a superb job of putting the death of the Clinton healthcare plan in context, explaining how a combination of “bad timing, political misjudgment and human error” conspired to kill what had been a “courageous effort” to pass health reform.)

But now, Begala and Greenberg say, the time is ripe for radical reform. They make their argument based both on the fact that the conservatives are in disarray and on what Americans now say when they talk to pollsters about healthcare reform.  In September, 62 percent of those polled said that “rising health care costs are a very serious problem in the economy”—up from 50 percent a year earlier. And, as the recession deepens, that number is likely to climb.

HBO Documentary: Inside a Baghdad Hospital

Tomorrow (Tuesday) night, at 8:30, HBO will air a documentary titled “Baghdad Hospital: Inside the Red Zone.” The film offers an inside look at Al-Yarmouk hospital in Baghdad, as seen through the eyes of a doctor. Once an ordinary hospital, Al-Yarmouk has been transformed by insurgency and sectarian strife into a “field hospital in a civil war.” It is the epicenter of hope and despair for thousands of wounded Baghdad civilians and their families. 

Filming inside Al-Yarmouk’s emergency room was too dangerous for an American crew to attempt.  Only an Iraqi ER doctor could do the job.  This is his story.

With the film’s debut on HBO, Dr. Omer Salih Mahdi reveals his identity to the world for the first time. Until now, he has remained anonymous to protect himself and his family. Dr. Mahdi's face is not revealed in the film and an actor has recorded his words.

Given permission by hospital authorities to use a hand-held camera inside the emergency room, Dr. Mahdi reveals some of the horrific injuries sustained by Iraqi men, women and children, and exposes the substandard conditions, low morale and danger that its doctors and nurses endure on a daily basis.

Like the American GIs in HBO's acclaimed 2006 documentary "Baghdad ER," many of the people hospitalized in this film are victims of gunfire or improvised explosive devices (IEDs). Here, however, the victims are Iraqi civilians caught in the crossfire of the ongoing sectarian violence between Iraqi Shiites and Sunni insurgents.

Life inside the hospital is dangerous: Gunshots frequently ring out inside the ER, and insurgent militia fighters often storm its doors. Doctors are targets, partly because, as one puts it, "We'll treat anyone: Shiite, Sunni, whoever." But it's much more treacherous for those working outside. Ambulances are sometimes shot at and ambulance workers have been killed, either mistakenly by Americans or deliberately by extremists.

The Prostate as Crystal Ball

A few days ago, Merrill Goozner at Gooznews posted a great commentary on a recent New York Times article that reveled in the so-called “revolution in medical prognostication.”

This time, the amazing innovation is a DNA test that helps to predict mens’ risk of getting prostate cancer at the low, low price of $300. But as the article points out, this test “cannot predict which men will get aggressive cancers” and thus “could lead to more screening and unnecessary surgery and complications.” In other words, it gauges the risk—not the inevitability, and not the severity—of prostate cancer. Defenders of the test say that if all goes according to plan, men “may want to get the new genetic test when they are young” so that they can get a jump on prostate cancer treatment.

But here’s the problem: prostate cancer treatment is, more often than not, less useful than you might think. Merrill points out that it’s “already overdiagnosed and overtreated with horrendous side effects for thousands of late middle-aged men.” Here at Health Beat, Maggie has also noted that while the risk of prostate cancer is often hyped, almost every authoritative medical body on the matter agrees that the benefits of screening and treatment of early-stage prostate cancer are highly uncertain. There is no evidence that early treatment prolongs life by a single day.  We excel at finding out if there might be the need to do something, but we know very little about the impact of what it is we actually do.

D.C. Dispatch: Pelosi Speaks

Today I’m in Washington, attending Health Action 2008. Families USA organized the event and invited me to come down and blog about it. Yesterday morning we heard Congresswoman Nancy Pelosi lay out her views on the health care issues facing Congress and I was both surprised and impressed by the strength of her speech.

Pelosi stressed equality: “We must fund bio-medical research,” she declared, “and the benefits must belong to every single American.”  She went on to point out that “in order to have this research available to all, we have to have a common electronic record—bringing everyone into the loop.” In other words, a single electronic medical record could provide the database everyone needs to see what works and doesn’t.

To be truly valuable, that database must be as broad as it is deep. As Pelosi put it, “the healthcare of the most privileged person in American benefits if everyone has health care, and if we have a common electronic record.”  (Pelosi also emphasized that this record must respect the privacy of everyone involved, keeping medical information about individuals confidential.)

She went on to say that while “bringing everyone into the loop, we must eliminate the disparities [in the quality of care that different groups in this country receive], not just from a sense of fairness—which would be justification enough alone—but in terms of insuring better health for the nation.”

Learning from Lipozene: The Anatomy of a Drug Scam

Yesterday I was watching television and was bombarded with the following infomercial for a dietary supplement called Lipozene:

No doubt your bull-you-know-what detectors are going haywire already, as well they should. But before you write off Lipozene as a joke, consider this: there’s nothing that the manufacturer of Lipozene—the Obesity Research Institute (ORI)—does that prescription drug companies don’t do every day. In fact, by analyzing Lipozene’s marketing, we can get a clear picture of the fundamental building blocks of Big Pharma’s business practices.

The active ingredient in Lipozene is glucomannan, a complex carbohydrate found in the konjac plant. Since glucomannan is an insoluble fiber, it absorbs water to form a thick gel that coats the stomach, making you feel full—thus reducing your eating.

For all that ORI’s advertisement irritates, it does contain a kernel of truth: the appetite-suppressing effects of glucomannan have been shown to help weight loss. A 1984 study showed that 1 gram of glucomannan before meals helped obese people lose an average of 5.5 lbs over eight weeks. Of course, this specific number is never cited in the Lipozene materials, with advertisements instead touting the fact that 78 percent of every pound loss was pure body fat and that “people were not asked to change their daily lives.”

Health Care Spending: The Basics; Spending on Physicians' Services-Do We Spend Too Much? Part II

As part of a continuing series on health care spending, last week I looked at what share of our health care dollars goes to pay for physician’s fees and clinical services. As the pie chart below shows, 22 percent of the $2.1 trillion that we spent  on  health care last year went directly to doctors. That’s up from 19.4 percent in 1960.

Most of the jump came in the 1960s and 1970s—though physician incomes continued to grow in the 1980s, rising 30 percent from 1984 to 1989, or about twice as fast as the average increase for other full-time workers.

I promised that this week I would publish a Part II to last week’s post and look at how much doctors are paid in other countries, how hard they work compared to doctors in the U.S., and how patients are faring as physicians’ incomes continue to outstrip both inflation and wages nationwide.  Finally, I said I would discuss whether we are spending too much on physicians services—and how we might change the way we pay them.

But first, let me very quickly re-cap the background to this story. In recent years, doctors’ fees have come under pressure. In the 1990s, managed care companies set out to pare costs by questioning virtually every bill that doctors sent them and in recent years Medicare has been trying to keep a lid on spending by refusing to raise most doctors’ fees.  Many private insurers have been following Medicare’s lead. Meanwhile, the cost of running a practice has been climbing, making it hard for some doctors (particularly primary care physicians) to stay afloat financially.

Nevertheless, by increasing the number of patients they see and the number of procedures they perform, many doctors have been able to boost their incomes.  More entrepreneurial doctors also have been making investments in surgical centers—creating a second income stream.  Thus, the overall amount that we spend on physicians’ services continues to rise: up 6.2 percent in 2000, up 8.3 percent in 2003, up 7.3 percent in 2004, up 7.4 percent in 2005, and gaining another 5.9 percent in 2006. 

But not all physicians are prospering. The charts I ran last week show pediatricians, family doctors and others who practice what some call “cognitive medicine” (talking to and listening to the patient ) making as little as $115,000 a year while specialists who perform the most aggressive procedures haul home $800,000.

Health Care Spending: The Basics; How Much Do We Spend on Physicians Services? Could We Spend Less?

As a nation, we are spending well over two trillion a year on health care. What exactly are we paying for? In a December 6 post, I asked how much of that $2 trillion goes to private insurers in order to cover “administration”-- which includes advertising, marketing, underwriting, lobbying, multi-million dollar executive salaries, and profits for  shareholders.   

As the pie chart below shows, it turns out that in 2006, after taking in premiums and  paying out reimbursements,  private insurers  kept  close to $95 billion—or about 4.5 percent of the $2.1 trillion we spent on care—to fund everything from advertising to CEO bonuses.  Meanwhile, private insurers paid roughly one-third of the nation’s health care bills.  (By contrast, the government picked up nearly half of  the $2.1 trillion tab through programs like Medicare, Medicaid, SCHIP while spending only $525 billion —or about 2.5 percent of the $2.1 trillion—on administration.)

Ninety five billion dollars represents the difference between what private insurers received in premiums and what they paid out in reimbursements, and it’s a big number. But as I commented in my December post, even if we eliminated the private insurance industry’s role in our health care system, the $95 billion saved would be wiped out by just one year of health care inflation.

Inflation: that is the elephant in the middle of the room. In 2006, total spending on health care climbed by 6.7 percent, or $132 billion, to $2.1 trillion. In 2007, economists expect an even bigger jump.The pie just keeps on growing, year after year, far faster than the average workers’ wages: up 8.6 percent in 2003, up 6.9 percent in 2004, up 6.5 percent in 2005, up 6.7 percent in 2006…And there’s no end in sight.

Shocking, SHOCKING News

Okay, not really—but still, unsettling news from yesterday’s NEJM. According to a report from professors at Oregon Health and Science University, Kent State University, and Harvard, negative studies of anti-depressant publications are much less likely to be published in research journals than positive ones.

The authors compared 74 FDA studies for 12 antidepressant agents, which involved a total of 12,564 patients, to those published in medical journals—the goal being to see which studies made it from the insider circuit to the printed page, and how those that did make the jump were altered for publication.   

They found that among the FDA-registered studies, “studies viewed by the FDA as having negative or questionable results were . .  . either not published (22 studies) or published in a way that . . . conveyed a positive outcome (11 studies).” In other words, bad news didn’t make it to the journals—or it was spun to sounds like good news.

Indeed, according to the study, if a reader were to judge the medications solely based on the published studies, they would think that “94 percent of the trials conducted were positive.” But in fact, “the FDA analysis showed that 51 percent were positive.”

Obviously, medical journals are publishing research that over-sells the effectiveness of anti-depressants. But why? The answer is exactly what you think: a big, fat conflict of interest. Medical journals have a lot to gain by giving designer drugs the benefit of the doubt—even if it’s undeserved.

In a well-known 2006 BMJ study, professors from York University and the University of Medicine and Dentistry in New Jersey, analyzed the messy world of “commercial bias in medical journals.” The risk here is self-explanatory: sometimes the business of medicine encroaches on medical research, especially when it comes to prescription drugs.

But despite the ubiquitous for-profit interests circling around medical journals, the BMJ study found that only nine of 30 peer-reviewed general and internal medical journals “had an explicit policy for dealing with editors' financial conflicts of interest.” The rest pretty much just wing it—a dangerous strategy when their publications are so economically vulnerable.

Retail Health Clinics: A Hidden Agenda?

You’ve probably heard of retail health clinics (RHCs), “drive-thru” medical centers that offer relatively simple and cheap medical services in stores like CVS and Wal-Mart. They’re all the rage nowadays, with their number doubling over 2007, from 300 to about 600 nationwide. At the end of this year, their numbers are expected to triple, hitting 1,800.

The RHC explosion has caused concern in some circles.  Primary care physicians are particularly worried that the clinics represent a threat to their practice and could disrupt continuity of care. Other concerns come from people like yours truly, who worry that the old formula of profit motive plus market opportunity could lead to a feeding frenzy that would compromise the quality of care.

Retail clinics are so new that these concerns can sometimes seem premature; but judging by one 2007 document that I recently came across, my worries are well founded. Even the people trying to grow the RHC market see these health care problems coming—but they view them as business opportunities.

What people often forget about for-profit initiatives like retail clinics is that they’re bent on growth. They may start small, but they don’t want to stay small. The business plan goes beyond today’s headlines. Investors want projections; they want a roadmap to the future; they want to know that challenges have been accounted for. That means that RHCs aren’t just concerned with the here and now, but also how the market can sustain itself in the future. And according to “Business Intelligence to Achieve the Goals of Retail-based Clinics,” a briefing from the Business Intelligence Network authored by Scott Wanless, the only way to do that is to look well beyond the current RHC formula.

Update No. 3 on the Checklist story

At Wachter’s World, Bob Wachter, Professor and Associate Chairman of the Department of Medicine at the University of California, San Francisco explains more about how the government’s attempt to stop the use of checklists in ICUs could undercut efforts to improve quality in hospitals nationwide.  He also gives you a chance to write to your Senator or Congressman. Go take a look.

WSJ Editorial on Liver Transplants Cherry-Picks the Numbers

Dr. Scott Gottlieb, a resident fellow at the conservative American Enterprise Institute, published an op-ed in the Wall Street Journal last week that returned to the much-exploited story of Nataline Sarkisyan, the 17-year-old Californian who died before receiving a liver transplant. Gottlieb used the story to make the argument that “the U.S. has the best health care in the world.”

Gottlieb is squaring off against John Edwards, who has been suggesting that if Nataline had lived in a European country she might have lived.  Edwards blames CIGNA, her for-profit insurer, for refusing to cover the procedure. Dr.  Gottlieb, who is a former FDA official, responds with a double-barreled argument: “Americans are more likely than Europeans to get an organ transplant, and more likely to survive it too.”  He sounds confident, and at first glance, his argument seems persuasive.

But a closer look reveals that Gottlieb makes his case by carefully culling the numbers that fit his argument, while omitting those that don’t. Unfortunately, too many people involved in the healthcare debate play fast and loose with the facts. Everyone interested in reform should be on the look-out for those who don’t cite solid evidence for their assertions. If they don’t give you their source, it may be because they don’t want you to look it up—and because they realize that they are cherry-picking the numbers.

Before engaging Gottlieb’s argument, I should acknowledge that, as I have said in an earlier post, I think Edwards has picked a bad case to make his argument for healthcare reform. I am not at all certain that the transplant would have helped this particular patient.  And while Edwards puts all of the blame on CIGNA, Nataline’s insurer, I am bothered by the fact that the hospital asked for a $75,000 down payment on the surgery and then refused to go forward without it. As one physician/blogger from the very same hospital where Nataline was treated asked: “Why didn’t the hospital simply perform the surgery and defer payment from the family or CIGNA [Nataline’s insurer] until later? If it was such a great idea, why didn't they exhibit the outrage and strength of conviction to go ahead regardless of CIGNA's assessment?” 

That said, I agree with Edwards and other proponents of health care reform that, in other countries, decisions about whether or not to pay for expensive procedures like transplants are not based on whether the patient has the money or the insurance to pay for the operation. Instead, in other developed countries, such decisions turn on whether the benefits of the treatment outweigh the risks—and whether the procedure is cost-effective.

Glenn Beck Gives Birth to a New Health Care Myth

Over on CNN.com, I came across one of the most wrong-headed arguments against health care reform that I’ve ever seen in my life. Here’s the gist of it: we can't reform the health care system until doctors are nicer to their patients. Perhaps unsurprisingly, this gem comes from a TV pundit.

The talking head in question this time is the lamentable Glenn Beck, CNN's go-to ‘irreverent conservative’ voice. In an online Op-Ed, Beck details his miserable experience with doctors after getting surgery and works very hard to turn his displeasure into an argument against health care reform—with little success.

Long story short, Beck had surgery on his butt, things went horribly awry, and he was seriously medicated in order to dull the pain. The combination of drugs Beck received “took [him] to an incredibly dark place...Every time I closed my eyes…I would see horrific, unimaginable images of death and after two and a half days…I was literally suicidal. It felt like there was no hope…”

Beck’s despair went more or less ignored by doctors, who he says "treated [me] more like a number than a patient. At times, staff members literally turned their back on my cries of pain and pleas for help. In one case a nurse even stood by tapping his fingers as if he was bored while my tiny wife struggled to lift me off a waiting room couch."

This is unsettling stuff that I wouldn't wish even on Glenn Beck. Predictably, but not unjustly, Beck uses his experience as a launching pad to assert the importance of compassion and bedside manner in medical professionals. Here here! But then Beck really, really jumps the tracks:

Health Wonk Review Is Up

Health Wonk Review is up here. This compendium of some of the best health care posts of the past two weeks is well worth reading. 

This week, Bob Laszewski of Health Care Policy and Marketplace Review  is our host, and he is highlighting pieces that examine some of the candidates’ health care plans (Joe Padua on John McCain, Jason Shafrin on all of the Democrats, and Anthony Wright comparing candidates on both sides of the aisle) as well as California’s effort at health reform (Brian Klepper is skeptical). He also calls attention to Roy Poses' expose of yet another greedy CFO on Health Care Renewal.  But I’m not going to try to list everything here. Check out Health Care Policy and Marketplace Review yourself—I suspect you’ll wind up putting it on your “favorites” list.

Turf Wars: Doctors Battle Over Some Procedures While Avoiding Others

Earlier this week the Happy Hospitalist, an internist who works full-time in a hospital,  published a behind-the scenes look at the “turf wars” that doctors fight when it comes to performing certain very lucrative procedures.  Colonoscopies, for example, pay nicely, and doctors vie to do them. Bone marrow biopsies, on the other hand, belong to the group of procedures he labels the “red headed step children” of hospital care:  they’re relatively time-consuming and just don’t pay very well. As a result, the (usually) Happy Hospitalist explains, he often has a very tough time finding a specialist willing to perform one of these procedures for a patient.

Let me preface his story by pointing out that Medicare’s fee-for-service payment schedule—which has become the basis for most private insurers’ payments as well—is set and updated by a proprietary, and rather secretive advisory committee, the RVS Update Committee (or RUC).

I’ll tell you more about the RUC in the post below (“Who Decides How Much To Pay Specialists?”)  But first, read the Happy Hospitalist’s story. (Note, throughout the piece, I have inserted definitions of medical terms, in brackets.)

From: The Happy Hospitalist
TUESDAY, JANUARY 8, 2008 
“Red Headed Step Children”

“In the world of procedures, all procedures are not created equal. And when that happens, the turf wars begin. I can assure you, in just about every hospital in this country, behind the scenes politics go hand in hand about who has the right the perform what. The battles usually ensue in those procedures that are economically worth while to the doctor or group of doctors

Who Decides How Much Specialists Are Paid?

If you’ve read the post above about specialists vying to do lucrative procedures like colonoscopies-- while avoiding equally time-consuming procedures that just don’t pay as well--you might have wondered: who sets and updates the fees for each procedure?

The answer: a Medicare advisory committee called the RVS Update Committee (or RUC).  The RUC flies under the radar. It’s quite secretive and many people have never heard of it. Yet it is enormously powerful. It sets the prices for Medicare’s fee-for-service payment schedule, a price-list that has become the basis for most private insurers’ payments as well.

Who is on the RUC? It’s dominated by specialists. So, it should come as no surprise that a specialist’s time is deemed to be worth far more than an internist’s or a family doctor’s time.  An article in the June 2007 Annals of Internal Medicine provides a quick example.

In 2005, the Medicare fee for a typical 25- to 30-minute office visit to a primary care physician in Chicago was $89.64 for a patient with a complex medical condition (Current Procedural Terminology [CPT] code 99214). By contrast, Medicare’s fee for a gastroenterologist in the outpatient department of a Chicago hospital performing a colonoscopy (CPT code 45378)--which also takes about 30 minutes—was $226.63.  And if the specialist performed the procedure in his own office, where he pays for equipment and nursing time, he could charge Medicare $422.90 for his thirty minutes.  (Of course the primary care physician also has to pay for staff and equipment, though the equipment may not be as expensive.) 

Health Care and—Not or—the Economy

Yesterday Maggie posted on how economic insecurity and health care are in fact related issues. I agree 100 percent, and wanted to take the opportunity to show that the American people concur. Health care costs and economic insecurity aren’t in competition for public mindshare—according to poll responses at least, the two are coupled.

Every year Gallup asks voters “Are you generally satisfied or dissatisfied with the total cost of health care in this country?" Check out the results from 2001 through 2007 below.

The trend toward being more worried about price of health care is clear. And inherently, cost worries are economic issues.

But the connection between economics and health care goes well beyond this logical argument—you can actually see the two linked in polls. Take a look at the graphs below (click both to enlarge them), from a Kaiser Family Foundation report published last month. Since 2004, Kaiser has been asking respondents how worried they are about a set of potential problems. The first set of bars shows that flagging incomes and high health care costs are the two major concerns that people say they are “very worried” about. This makes sense: the less confident you are about your purchasing power, the more worried you’ll be about buying essentials like health coverage.

The Newest Last-Place Finish for U.S. Health Care

Many people—okay, mostly conservative politicos—like to say that the U.S. has the best health care system in the world. Time and again, those of us in the reality-based community offer a legion of evidence as to why this isn’t true; the ethno-centrists wag their fingers and repeat their refrain; and so the cycle continues.

But recent numbers from the Commonwealth Fund should put a stop to this cycle: the U.S. health care system places last in the world when it comes to stopping preventable deaths.  In other words, we spend more but accomplish less—does that sound like success to you?

The new study, funded by Commonwealth and appearing in the Jan/Feb ’08 issue of Health Affairs, looks at “deaths from certain causes before age 75 that are potentially preventable with timely and effective health care.” Relevant causes of death include diabetes mellitus, intestinal infectious diseases, whooping cough, childhood respiratory diseases, leukemia and others.

The authors, both from the London School of Hygiene and Tropical Medicine, found that America’s success in staving off these health problems has decreased over time. Between 1997/1998 and 2002/2003, preventable deaths fell by an average of 16 percent in all 19 industrialized countries considered; but the decline in the U.S. was only 4 percent. In 97/98, “the U.S. ranked 15th out of the 19 countries on this measure—ahead of only Finland, Portugal, the United Kingdom, and Ireland—with a rate of 114.7 deaths per 100,000 people. 

“By 2002–03, the U.S. fell to last place, with 109.7 per 100,000. In the leading countries, mortality rates per 100,000 people [for 2002-2003] were 64.8 in France, 71.2 in Japan, and 71.3 in Australia.” [see graph below, courtesy of Commonwealth]

Election Watch—Reframing the Issues: It’s the Economy Stupid!

On Gooznews last week, Merrill Goozner made a provocative argument:

“…the latest polls show the economy has eclipsed health care as the most important domestic issue among voters. Even the health care-oriented Kaiser Family Foundation's latest poll shows the number of Americans who name health care as their primary concern fell to 30 percent in early December from 38 percent just two months earlier. When offered a list of possible issues the candidates ought to address, the economy had pulled even with health care.

“The escalating fear that the nation may be heading into a recession because of the sub-prime mortgage meltdown and sky-high gas prices has certainly played a role in the turnabout. In that sense, 2008 is beginning to look a lot like 1992. The year before that election, health care dominated the national discussion after Harrison Wofford used the issue to win a surprise victory in a special Senate election in Pennsylvania. But by the time Arkansas Gov. Bill Clinton stormed to victory in the primaries, ‘it's the economy, stupid’ had become the Democratic standard bearer's watchword.”

Merrill may be right: certainly health care didn’t seem to be the driving issue in Iowa, and I doubt it will determine the results in New Hampshire. (See my last post on Iowa and New Hampshire.)

And I agree that, by November, the economy may well be the paramount issue. We are heading into a recession.

How Are Iowa and New Hampshire Different From the Rest of the Country?

When it comes to health care, the citizens of Iowa and New Hampshire are different from you and me: they enjoy higher quality yet much more affordable health care than citizens in virtually any other state. This may help explain why health care just hasn’t seemed to be a pivotal issue in these early primaries.

The chart below (click the image for a bigger version in a new window), published in Health Affairs in 2004, rates the quality of  health care state by state (see vertical axis) while also revealing how much Medicare spends, on average, per beneficiary in each of the states each year. (See horizontal axis.) Spending has been adjusted to take into account inflation, differences in prices in different states, and differences in the age, sex and race of the Medicare population in each state.  States that spend most appear on the far right of the chart. States that provide the highest quality health care are clustered at the top.

Obama’s Win: Can Conservatives and Progressives Unite on Health Care Reform?

Yesterday I appeared on a four-person health care panel that was televised in New Hampshire.  The panel included a conservative who surprised me by arguing that the difference between the progressive candidates’ proposals for health care reform and the conservatives’ position on health care just isn’t that great.

Looking at the candidates’ proposals, I disagreed.  Put simply, the conservatives would like to make government smaller. They want to “outsource” many of government’s jobs to the private sector. They tried to privatize Social Security, and they have partially succeeded in privatizing Medicare by paying private insurers a steep premium to take care of seniors under Medicare Advantage. (See my post about the high cost of the program here).

Finally, the vote on SCHIP split along conservative/ progressive lines, with conservatives voting against expanding SCHIP. As President Bush explained, more funding for SCHIP would expand the government’s role in our health care system.

Update No. 2 on the Checklist story

I promised to return with more information about who halted the use of life-saving checklists in Intensive Care Units in Michigan and at Johns Hopkins. (For my earlier posts on this shocking story, click here and here).

The Office of Human Research Protections (OHRP) is the agency that has nixed the use of checklists. Who runs the OHRP?  Until his recent resignation (as of Sept. 30), Bernard Schwetz was the director of OHRP. Who is Schwetz? He is a veterinarian (DVM). That’s right, he’s vet, not a M.D.

What’s even more surprising is that from January 20, 2001 to February 2002, Schwetz, who is also a toxicologist (Ph.D.), was Acting Deputy Commissioner of the FDA. This was not a bright period in the FDA’s history. During Schwetz’s tenure, the FDA’s counsel, Dan Troy, was running the agency from behind the scenes. Troy, a Bush appointee, was well-known as a long-time foe of FDA regulation. In the 1990s, he represented Brown & Williamson Tobacco Corp. in its effort to fend off the FDA, and just months before joining the agency, he had defended Pfizer in another battle with regulation. As a U.S. News & World Report headline summed up his career change: “Mr. Outside Moves Inside: Daniel Troy Fought the FDA for Years; Now He’s Helping to Run it.” (I have documented Troy’s power in my book, Money-Driven Medicine).

As for Schwetz, what can one say about a vet/toxicologist who becomes temporary deputy commissioner of the FDA? “Political appointee” is the phrase that comes to mind.

I’m told that the OHRP is a “strange creature.” It was created in 2000 to replace the small, underfunded Office of Protection from Research Risks. That office reported to the NIH. OHRP, by contrast, reports directly to the Assistant Secretary of Health, putting it under the White House’s control.

OHRP began sending what only can be described as threatening letters to Michigan and Johns Hopkins last summer—on Schwetz’s watch. He announced his resignation at the beginning of August. I haven’t been able to find an explanation for the resignation or whether it is in any way connected to OHRP’s decision about the checklist.

Keep Criminals Healthy—Or Else

One of the most infamous records the U.S. holds is that of the world’s incarcerator. As of 2006, 2.2 million Americans were incarcerated, more than even China—which has over four times the population of the U.S.

California is the most cell-happy state in the union, with its prison population in midyear 2006 at over 175,000, or 11.3 percent of the total prisoners in the country.  The Golden State’s 175,000 inmates are held in 33 prisons—meaning there’s roughly 5,307 inmates per prison.

Put differently, every prison health care system has 5,307 potential patients, day in and day out. That’s quite a caseload, and it’s made much worse by the fact that prisoners are in much poorer health than the general population. Indeed, the California prison system is in the throes of a health care crisis—one that highlights why we should all care about the quality of medical services for inmates.

As you might guess, prison is an unhealthy place. Prisoners are more than eight times as likely to be infected by HIV, four times as likely to have active tuberculosis, and more than nine times as likely to have hepatitis C. According to the National Commission on Correctional Health Care, about 3 percent of the U.S. population spends time in prison or jail—but between 12 and 35 percent of the total number of people in the nation with some communicable diseases (like AIDS and Hepatitis B) pass through a correctional facility.

Commission data shows similar trends occur for mental illnesses (see the table below). Prison inmates have rates of schizophrenia and other psychotic disorders that are three to five times greater than the general population. Their incidence of bipolar disorder is up to three times greater than people outside prisons. And prisoner rates of drug and alcohol abuse are also higher.

Bad Cases Make Bad Law

Perhaps you saw the headlines over the holidays:

• “CIGNA Defends Decision To Let Teen Die—On Christmas Eve”
• “As CIGNA Insurance Waffles on Liver Transplant, Girl Dies”
  
• “Lawyer: CIGNA's refusal to pay for liver transplant 'killed' teen”
  
• “Teenage Girl Dies So CIGNA Execs Can Get Richer”
  
• Metroblog: "Merry ******* Christmas, From  CIGNA Healthcare "

Without question, this is a tragic story. Here are the bald facts: Nataline Sarkisyan, a 17-year-old who had been battling leukemia for three years, received a bone marrow transplant from her brother the day before Thanksgiving. She then suffered complications; her liver failed, and she went into a coma. At that point her doctors at the UCLA Medical Center recommended a liver transplant, saying that the transplant would give her a 65 percent chance of living another six months.  Within four days, a matching donor was found.

But on December 11th her insurer, CIGNA, refused to cover the transplant on the grounds that for a patient this sick, the transplant would be an “experimental procedure.” And her insurance policy "does not cover experimental, investigational and unproven services.” 

The doctors told the family that their only alternative would be to make a $75,000 down payment on the operation. Unfortunately, the family didn’t have $75,000. 

Observers both in the mainstream media and in the blogosphere were outraged when they heard that CIGNA had denied coverage.  Daily Kos led the protest with “Murder By Spreadsheet: CIGNA  Denies Claim and 17-Year-Old Will Die.” Responding to the firestorm, on December 20 CIGNA relented, saying that  "despite a lack of medical evidence regarding the effectiveness of such treatment,” it would cover the transplant.

The letter from CIGNA came too late. That same day, the hospital called to say that Nataline's condition was deteriorating and her family was forced to make the decision to take her off life support.  She died within the hour.  The next day the Sarkisyan’s lawyer announced that the family planned to sue CIGNA for “malicious” murder.

This is both a tragic tale and a complicated story—far more complicated than the headlines suggest.  As Dr. John Ford, an assistant professor at UCLA’s medical school observed on his blog, California Medicine Man, “While I'm not surprised at the intensity of emotion that has arisen from this case, the utterly inflammatory and often mindless rhetoric being propagated is sobering. It seems that nuance has taken a hike, never to reveal itself.” 

Here are just a few of the questions that this vexed and vexing case raises: