Getting More Value from Medicare

With Medicare’s financing unraveling, Medicare reform will need to be high on the next president’s agenda. In a new report from The Century Foundation, fellow and HealthBeat Blog editor Maggie Mahar (www.healthbeatblog.org) points out that past proposals for containing Medicare’s costs, such as putting a cap on physicians’ fees or requiring beneficiaries to pay more for their care, have not worked. She calls for a fundamental set of reforms that would not only save money but also improve the quality of care that beneficiaries receive.

You will find the report at www.tcf.org later today.

An Update on Gardasil

Over at the Center for Media and Democracy’s PR Watch http://www.prwatch.org/node/7748  Judith Siers-Poisson writes:

“With the start of the school year, debate has heated up again about Gardasil, Merck's vaccine against human papillomavirus. Since writing my series of four articles on The Politics and PR of Cervical Cancer last year, I have continued to track the developments

“The push for mandatory vaccination continues, and many of its supporters have received money from Merck, including Women in Government, about whom I wrote extensively in my article, "Women in Government: Merck's Trojan Horse." Despite a palpable turning of the tide against mandates, Women in Government still swims against the current. In a 2008 report titled "State of Cervical Cancer Prevention in America," WIG continued to push for mandates and gave higher scores to states that have introduced or passed legislation for this purpose.”

Obama vs. McCain: Their Health Care Plans; An Attempt at Nonpartisan Analysis-- Part 1

Each presidential candidate offers a blueprint for health care reform. Neither can expect to see his plan enacted whole—legislators will leave their fingerprints all over any proposal. And, if truth be told, neither plan is perfect. Each proposal is blinkered in its own way; each ignores just how difficult true reform will be. I very much doubt that national health insurance will become a reality in the next year.

That said, I believe that we can take steps toward reform in 2009 if we begin thinking clearly—and honestly—about exactly what it is that we want and what it will cost. To that end, I believe that in-depth analysis of each candidate’s proposal can help underline the core ideological differences between conservatives, libertarians and progressives, and highlight the economic realities that any reform plan will have to face.

Recently, opponents of each plan have offered their critiques in Health Affairs (here and here) and supporters have defended their favorites  here  and here. Inevitably, many readers found the critiques too partisan. At the same time, they complained that rebuttals from the home team “read more like a stump speech with details glossed over and facts overlooked.”   

Readers are still looking for an unbiased, in-depth report on the two plans that clarifies the details and the differences. Earlier this week, the Urban Institute, a nonpartisan economic and social policy research organization, published an assessment of the two proposals that sets out to do just that. Overall, the Institute’s report seemed to me remarkably fair—and certainly worth discussion. 

The Strengths of the Obama Plan 

First, the Institute notes, rightly, that Obama’s plan would “substantially increase access to affordable and adequate coverage for those with the highest health care needs, including those with chronic illnesses” by:

Whatever Happened to Bedside Manner?

I’ve said it before, and I’ll say it again: the doctor-patient relationship is just that—a relationship, a mutual connectedness between two human beings, each with their own values, dispositions, and priorities. Like all relationships, this one is complex, but there is a single concept that manages to capture a lot of what doctors are expected to bring to their partnership with patients: empathy.

Empathy is key to what we’ve traditionally called “bedside manner,” or the ability of doctors to identify with the concerns and emotions of their patients in order to reassure them and more generally ensure effective communication. Every one of us probably has an intuitive understanding of why empathy is a valued trait in doctors, but it’s worth exploring the issue further—especially since it seems to be in short supply amongst today’s doctors, in part thanks to the rigors of medical school.

We’re not talking about warm and fuzzy nonsense here. Empathy is “more than a nice idea,” say Donald Scott and William R. Harper, two professors at the University of Chicago, “it’s a pragmatic skill that stands at the center of the patient-doctor connection, on which so much else depends.” That skill isn’t just about feeling for patients, but also about expressing those feelings, through words, body language, and tone. In 2006, Harper gave the University of Chicago Magazine an example of empathy’s importance: “If the connection is strong, the patient is more likely to follow a doctor’s recommendations. You can order the fanciest test in the world but if the patient does not buy into it, it doesn’t matter.”

The best way for patients to ‘buy into’ treatments is to feel that their doctors understand and appreciate their situation.  “Irrespective of the disease, when you find someone who will feel for you, you feel better,” U of C neuroscientist Jean Decety told the university magazine. Indeed, studies show that a stronger doctor-patient relationship contributes to improved health outcomes by ensuring that health situations are clearly understood and patient priorities are met. Empathy also reduces the burden on the friends and family who care for terminally ill patients.

Congratulations to Drs. Diane Meier and Peter Pronovost

Yesterday, the John D. and Catherine T. MacArthur Foundation named 25 new MacArthur Fellows for 2008. The recipients will each receive $500,000 in "no strings attached" support over the next five years. The new Fellows work across a broad spectrum of endeavors and include a neurobiologist, a saxophonist, a critical care physician, an urban farmer, an optical physicist, a sculptor, a geriatrician, a historian of medicine, and an inventor of musical instruments. All were selected for their creativity, originality, and potential to make important contributions in the future.

HeathBeat has written about both Meier (the geriatrician) and Pronovost (the critical care physician). To read their stories, click here and here. Meier also is a member of the working group on Medicare Reform that I have put together here at the Century Foundation.

Please feel free to share your thoughts/comments about these pioneers and their work here on HealthBeat.

Most Results of Drug Studies Never Published

Today, The Guardian UK published a story that should be shocking--but isn't: "More than Half of U.S. Drug Studies Never See the Light of Day." This serves as further proof--if we needed it-- that pharmaceutical companies should not be allowed to control what doctors and patients know, and don't know, about new drugs.

The story follows below.

More than half of US drug safety studies never see the light of day
Only 43% of the evidence of safety and efficacy that the US Food and Drug Administration uses to approve drugs is published in scientific journals. The authors of the survey say this amounts to "scientific misconduct."

James Randerson, guardian.co.uk,Tuesday September 23 2008 10:46 BST

The results of more than half of all clinical trials that demonstrate the safety and effectiveness of new drugs are not published within five years of the drug going on the market, according to an analysis of 90 drugs approved by US regulators between 1998 and 2000.

The researchers, who traced the publication or otherwise of 909 separate clinical trials in the scientific literature, wrote that the failure of drug companies to publish the evidence relating to new medicines amounted to "scientific misconduct". They said it "harms the public good" by preventing informed decisions by doctors and patients about new medicines and by hampering future scientific work.

Consumer or Patient?

The newest edition of Health Affairs includes the story of Michelle Mayer, a patient whose odyssey seems to validate consumer-driven medicine—at least on the surface. But a closer look reveals that Mayer’s tale is no consumerist parable; in fact, it’s a great example of consumer-driven medicine’s shortcomings as a model for health care.

Mayer’s Story

At first glance, Mayer’s story seems to jibe with the ethos of consumer-driven medicine, with a well-informed, assertive patient cycling through obstinate doctors until she finally receives care that she felt was appropriate. The journey begins twelve years ago, when Mayer—a research assistant professor at the University of North Carolina School of Public Health—noticed swelling in her hands and was found to be producing a specific antibody associated with scleroderma, an incurable chronic autoimmune disease. Though Mayer “truly believed that [she] had scleroderma,” doctors diagnosed her with a less serious condition called Raynaud’s phenomenon.

But over the next year, Mayer began to experience symptoms consistent with scleroderma, like sluggishness, hardened skin, and uncontrollable itching. When she finally sought out a new rheumatologist, he confirmed that she did indeed have scleroderma. Irate that her passivity had contributed to the misdiagnosis of her condition, the then-newly graduated Mayer “put [her] new Ph.D. in public health to good use, devouring the medical literature on scleroderma.”

Health Wonk Review: Palin, Pete Stark, Ignagni and Schwarzenegger

This week the Disease Management Care Blog hosted Health Wonk Review, and did it with style. (http://diseasemanagementcareblog.blogspot.com/2008/09/welcome-to-health-wonk-review-political.html)

Spotlighting some of the best health blogs of the past two weeks, Jaan Sidorov noted that Joe Paduda, editor of Managed Care Matters, took on the “Free marketeers who have been lauding Gov. Sarah Palin's efforts to eliminate Alaska's restrictions on new health care technology and facilities.”  Paduda reminds his readers that we have “a long line of well-documented, rigorously-researched studies that clearly and unequivocally prove supply drives health care costs. The more health care facilities, beds, technology, the more physicians and care givers there are, the higher the cost and the worse the outcomes.”  In other words, there is good reason to restrict how much medical technology we purchase. If we buy more than a community truly needs, we’ll wind up with more overtreatment---and patients will suffer.

Meanwhile, Sidorov reports, over at The Health Care Blog, Matthew Holt has a little fun with America’s Health Insurance Plan’s President and CEO Karen Ignagni.  Its seems that Ignagni occasionally forgets that she earns her $1.3 million salary by heading up a trade group that represents for-profit insurers, and begins talking about how the insurance industry needs to make a profit because it wants to fulfill its “mission.”  As Matthew points out, “No Margin, No Mission” is the motto of non-profit hospitals –institutions that actually do have a social “mission” to serve their communities.

Neil Versel of the Healthcare IT Blog shares the good news and the bad news. The good: Rep. Pete Stark (D-CA) has introduced legislation with some commonsense reforms, including an open source EHR, the promotion of de-identified data use, and clarification of HIPAA. The bad: the likelihood that Stark’s legislation will pass? “Zero.”

Finally The New America Foundation’s  New health Dialogue blog asked Leif Wellington Haase, director of New America's California Program, and Micah Weinberg, a research fellow in the California program, to update readers on where health reform stands in California. Their entire post is well worth reading, but here’s the punch-line: “Governor Schwarzenegger’s will to pass health reform remains strong, but his approval ratings have tumbled and he even faces the possibility of a recall vote sponsored by the prison guards’ union.”  Only in California.

I’ve traveling, so I’m giving you just a light sampling of this particularly well written Health Wonk Review. Read the entire post by clicking (http://diseasemanagementcareblog.blogspot.com/2008/09/welcome-to-health-wonk-review-political.html

Health Care in Taiwan

My last foray into international health care systems focused on Singapore, a tiny island nation whose much-lauded health care system represents an interesting public-private mix. But there’s another island, not too far away, that also makes for a compelling case study in health care -- in this instance through a single-payer system: Taiwan.

A handful of commentators have already hooked onto the fact that Taiwan’s health care system provides an instructive example of single-payer: Merrill Goozner and Ezra Klein both noted a well-written Congressional Quarterly article on Taiwan’s system earlier this year, and British analyst Ian Williams writes lauds Taiwanese health care in the winter 2008 edition of Dissent magazine.

The buzz around Taiwan’s National Health Insurance (NHI) system stems from the fact that some of its vital stats are stunning, particularly in comparison to the United States. NHI covers 99 percent of the Taiwanese population; in the U.S., 15 percent of the population lacks health insurance. Taiwan spends a mere 6.2 percent of its GDP on health care; the U.S., 16.3 percent. Administrative costs make up only 1.5 percent of NHI’s budget, while administration accounts for about 7.5 percent of American health care expenditures.

Single-payer critics habitually fret about long wait times, but a 2005 article in the journal International Medical Management (IMM) reports that wait-times are almost non-existent in Taiwan, and that Taiwanese doctors cycle through patients speedily enough to “see approximately 50 percent more patients than their counterparts in the U.S. on a weekly basis.” All in all, Taiwanese are far happier with their health care system than we Americans are with ours: last year the national satisfaction rate with health care in Taiwan was 77.5 percent. By way of contrast, an August Commonwealth Fund poll shows that 82 percent of Americans think that the U.S. healthcare system should be fundamentally changed or completely rebuilt.

Admittedly, Taiwan’s single-payer system certainly isn’t all sunshine and rainbows--but it is instructive for those thinking about how to best reform the U.S. system. 

How U.S. Health Care Mirrors the Contradictions Ingrained in the Minds and Souls of America’s Citizens

Princeton economist Uwe Reinhardt is well known as one of the bluntest—and wittiest—critics of U.S. Healthcare.  Last week, we both spoke at a conference organized by Princeton’s Policy Research Institute on “Access to Universal Health Care: New Jersey, the Nation and the Globe. As usual, I learned something from Professor Reinhardt.

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Earlier this year, New Jersey Governor Jon Corzine received a somewhat startling letter from Princeton economist Uwe Reinhardt. The missive was appended to a report from the “New Jersey Commission on Rationalizing Health Care Resources,” a Commission that Corzine had asked Reinhardt to chair.

In the letter, Reinhardt expresses “some personal observations on the inconsistent expectations Americans have of their health system,” describing “these inconsistencies” as “a form of cognitive dissonance.”  Reinhardt goes on to explain that, in his view, these inconsistencies reflect “certain deeply ingrained traits in American culture that stand in the way of a rational health care system.”

He concludes: “In short, Governor Corzine, in my professional view, the extraordinarily expensive, often excellent just as often dysfunctional, confused and confusing American health system is a faithful reflection of the minds and souls making up America’s body politic.”

After reading the letter, Governor Corzine had one question: “You’re not going to publish this in the report, are you?”

In fact, the letter did appear at the front of the report. And last week, at a conference on “Access to Universal Health Care: New Jersey, the Nation and the Globe” sponsored by Princeton’s Policy Research Institute, Reinhardt circulated said letter.  It served as a good companion to Reinhardt’s speech, which compared what we euphemistically call our health care “system” to systems in other parts of the world.

Reinhardt began his talk by considering the fact that, in the U.S. insurance is often tied to one’s job.
“No one –in his wildest dreams—Drunk!!—would design a health care system based on employment,” Reinhardt declared, barely containing his outrage at such a truly bone-headed idea. After all, the unintended--but inevitable-- consequence of an employer-based system is this:  if you lose your job, you also lose your health insurance—at exactly the worst possible time.