Tuesday, January 31, 2012

The Washington Monthly - Ten Miles Square - The Quiet Triumph of Obama Care

The Washington Monthly - Ten Miles Square - The Quiet Triumph of Obama Care:

We understand why President Obama trumpeted the killing of Osama bin Laden while barely mentioning health reform, his most significant domestic accomplishment in his State of the Union address last week. Ten years after 9/11, the killing of Bin Laden was an indisputable triumph for President Obama, welcomed by almost every American. In contrast, the Patient Protection and Affordable Care Act (ACA), enacted with only Democratic votes by the scarcest of margins in 2010, remains a complex, highly controversial piece of legislation with outcomes and costs that remain to be seen in the years ahead.

Yet surprising even to many advocates of health care reform, evidence is emerging that the ACA is already improving life for millions of average Americans. It is promoting long-overdue fundamental changes in our dysfunctional medical system. Moreover, because those reforms are starting to directly address heightened economic insecurities of average families - the personal financial conditions that will largely determine this year’s election outcomes - President Obama would be wise to more forcefully and more specifically explain how his health care bill is already helping millions of vulnerable families and the country as a whole. Sure, financially-pressured families will celebrate the derring-do of Seal Team Six. They should directly appreciate the immediate impact of improved insurance coverage and reduced medical costs.

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Monday, January 30, 2012

The Facts On Massachusetts Health Reform – Health Affairs Blog

The Facts On Massachusetts Health Reform – Health Affairs Blog:

Last Thursday’s Republican Presidential Debate in Florida included a lively, but not always accurate, exchange on health reform in Massachusetts. In particular, Senator Santorum reported that one in four Massachusetts residents were going without needed care because of high costs; he also implied that the share of residents choosing to pay the fine for failing to comply with the individual mandate, and the share of residents who were free riders on the system, were serious problems in the state. None of that is true.

My colleagues and I have been tracking health reform in Massachusetts since 2006, with a summary of our most recent findings published in Health Affairs last week. As we report, Massachusetts continues to show strong gains in insurance coverage, access to care, and self-reported health status under reform, all important goals of the state’s 2006 legislation. Currently residents of the Bay State enjoy the highest level of insurance coverage in the nation, with most of that coverage provided through their jobs, as it was before health reform. As Governor Romney noted, a majority of Massachusetts residents continue to support the state’s reform efforts.

Contrary to Senator Santorum’s claims, very few residents of the state are “free riders” on the health care system in Massachusetts, moving in and out of coverage as they need care

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Friday, January 27, 2012

General Surgery News - Spam in a Can

General Surgery News - Spam in a Can:

For those of you who have been spending your days operating and taking care of patients instead of keeping up with the latest machinations from central planning to separate you from the fruits of your labor and control of your practice, ACOs are bundles of providers who will receive a global payment for a specific patient encounter, like a cholecystectomy. Who will bill, receive and divide the money is uncertain, except that it won’t be you, the surgeon. The only thing certain is that like diagnosis-related groups, the sustainable growth rate, and relative value units, this latest iteration in health care spending discipline will be gamed and ultimately relegated to the alphabet graveyard of designer cost-containment programs invented by health policy wonks who have an aversion to traditional medicine based on the private doctor–patient relationship. I’ll say this much for them: They are undeterred by their unbroken string of failures. Maybe they’re Cubs fans.

An interesting read, if you want to really appreciate the "old school" approach of a lot of our colleagues (this was sent to me by one). My thoughts:

Some interesting phrasing choices in this piece.
"outside secular influence"

"the surgical workforce has been transformed by macroeconomic factors from the ownership class to the labor class."

"Ownership and labor never agree on anything"

"Strip away the thin veneer of status, and the chief of surgery at Johns Hopkins and the junior surgeon at Kaiser both serve at the pleasure of a boss, punch a clock and take fire training and corporate compliance classes."

"you had the common values, aspirations and headaches typical of small-business owners."

"cookbook medicine" (Really? Who still thinks this way?)

Anyway, it all made me think of the Master-Slave morality dichotomy. Since Jesus was the epitome of the 'slave' side of this, I'm comfortable with my position, as is, I expect, is Dr. Russell.

And it also made me think of this great quote:

"A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it"
Max Planck

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Thursday, January 26, 2012

Higher Fees Paid to U.S. Physicians Drive Higher Spending for Physician Services Compared to Other Countries - The Commonwealth Fund

Higher Fees Paid to U.S. Physicians Drive Higher Spending for Physician Services Compared to Other Countries - The Commonwealth Fund:

Key Findings

Public payer fees for an office visit ranged from $34 in Australia to $66 in the United Kingdom; private payer fees ranged from $34 in France to $133 in the United States.
U.S. primary care physicians were paid an average of 27 percent more by public payers for an office visit, and 70 percent more by private payers for an office visit, compared with the average amount paid in other countries.
Public program fees for hip replacements ranged from $652 in Canada to $1,634 in the U.S. In the U.S., private health insurance fees for hip replacements were nearly $4,000—twice as high as the private rates in the five other countries.
U.S. payers paid much higher fees to orthopedic physicians for hip replacements: public payers paid 70 percent more, while private payers paid 120 percent more.
U.S. primary care physicians earned an average $186,582, compared with a range of $92,844 (Australia) to $159,532 (U.K). U.S. orthopedic surgeons earned an average $442,450, compared with a range of $154,380 (France) to $324,138 (U.K.).

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Editor of journal critical of welfare still has DPW job - Philly.com

Editor of journal critical of welfare still has DPW job - Philly.com:

INQUIRER HARRISBURG BUREAU HARRISBURG - A controversial adviser to Welfare Secretary Gary Alexander is still working for the state and will do so for an indefinite period, despite last week's announcement that he had resigned.

Last week, officials said Robert W. Patterson, a special assistant to Alexander, had quit his $104,470 position as The Inquirer was preparing to publish a story about his outside role as editor of a conservative, faith-based journal.

In announcing Patterson's exit, the Corbett administration distanced itself from views expressed in the journal, which has criticized key welfare programs administered by the Department of Public Welfare and offered opinions that women should be stay-at-home mothers and opposing birth control - as well as musings on how condom use could rob women of reported mood-enhancing benefits of chemicals in semen.
If you haven't read Thomas Frank's "The Wrecking Crew," this could be straight out of it. Hire someone who detests a government agency and especially its constituency, and put them in positions of power within that organization to make it weak and ineffectual, then decry it for being weak and ineffectual.

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Gingrich and Reagan - National Review Online

Gingrich and Reagan - National Review Online:

Off topic, but too fun to skip...

The best examples come from a famous floor statement Gingrich made on March 21, 1986. This was right in the middle of the fight over funding for the Nicaraguan contras; the money had been cut off by Congress in 1985, though Reagan got $100 million for this cause in 1986. Here is Gingrich: “Measured against the scale and momentum of the Soviet empire’s challenge, the Reagan administration has failed, is failing, and without a dramatic change in strategy will continue to fail. . . . President Reagan is clearly failing.” Why? This was due partly to “his administration’s weak policies, which are inadequate and will ultimately fail”; partly to CIA, State, and Defense, which “have no strategies to defeat the empire.” But of course “the burden of this failure frankly must be placed first on President Reagan.” Our efforts against the Communists in the Third World were “pathetically incompetent,” so those anti-Communist members of Congress who questioned the $100 million Reagan sought for the Nicaraguan “contra” rebels “are fundamentally right.” Such was Gingrich’s faith in President Reagan that in 1985, he called Reagan’s meeting with Soviet leader Mikhail Gorbachev “the most dangerous summit for the West since Adolf Hitler met with Neville Chamberlain in 1938 in Munich.”

Gingrich scorned Reagan’s speeches, which moved a party and then a nation, because “the president of the United States cannot discipline himself to use the correct language.” In Afghanistan, Reagan’s policy was marked by “impotence [and] incompetence.” Thus Gingrich concluded as he surveyed five years of Reagan in power that “we have been losing the struggle with the Soviet empire.” Reagan did not know what he was doing, and “it is precisely at the vision and strategy levels that the Soviet empire today is superior to the free world.”

There are two things to be said about these remarks. The first is that as a visionary, Gingrich does not have a very impressive record. The Soviet Union was beginning to collapse, just as Reagan had believed it must. The expansion of its empire had been thwarted. The policies Gingrich thought so weak and indeed “pathetic” worked, and Ronald Reagan turned out to be a far better student of history and politics than Gingrich.

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Wednesday, January 25, 2012

Front Group King Rick Berman Gets Blasted by his Son, David Berman | Center for Media and Democracy

Front Group King Rick Berman Gets Blasted by his Son, David Berman | Center for Media and Democracy:

Rick Berman's son, David Berman, is a 42-year-old singer-songwriter who, since 1989, has been the front singer for a popular New York City indie rock band called the "Silver Jews." Over the years, the Jews have developed a loyal following, but on January 22, 2009 David Berman stunned his fans by posting a note to an online message board announcing that after all these years he was leaving the Silver Jews. The reason? His father, Rick Berman.

In scathing language, David disclosed to his fans who his father is, and how leaving the band related to his father's work. David wrote,

...follow the link. Amazing stuff!

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GPs and healthcare costs | OECD Factblog

GPs and healthcare costs | OECD Factblog:

It may be common knowledge that doctors’ pay outstrips average wages, with the really high earnings going to medical specialists. But now, more and more doctors are becoming specialised, with implications for costs and healthcare policy more generally. There were some 3.2 million doctors in the OECD area in 2008, which is over 40% more than in 1990 in absolute terms. But looked at on a per head basis, the number of specialists expanded by about 50% over the same 18 year period, compared with a mere 15% rise per capita for GPs.As a result, the number of medical specialists now exceeds generalists in all but four OECD countries–Australia, France, Korea and Portugal. This trend towards specialisation may reflect advancements in medical technologies and the increasing complexity of healthcare. But it also reflects a a widening pay gap.

Indeed, despite the sharp rise in the number of specialists, their pay has grown faster than that of generalists in a diverse group of OECD countries, includingAustralia, Finland, Hungary and the Netherlands . Only in a few European countries, such as Belgium and Luxembourg, has the income of generalists grown faster than that of specialists.

Having more specialists is clearly not bad in itself, but a shift away from GPs can undermine primary care and increase costs pressures.

The UK is one country that has taken deliberate steps to improve the relative attractiveness of general practice . New contracts were introduced in 2004, and since then GP pay has risen sharply. Whether the extra cost incurred in improving the GP contracts has delivered value for money is less clear. But the search for policies to encourage a more effective GP/specialist balance is set to continue.

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Tuesday, January 24, 2012

Like it or not, Obamacare forces drug company disclosure - News - ReviewJournal.com

Like it or not, Obamacare forces drug company disclosure - News - ReviewJournal.com:

The New York Times and the Wall Street Journal have taken the lead in writing about potential conflicts of interest between doctors and medical manufacturers. Although philosophically on opposite sides, both newspapers have raised questions in chilling stories about doctors taking money from drug and device manufacturers.

The Times' reported that some doctors practice medicine differently if they take money and are more willing to prescribe drugs in risky and unapproved ways.

In the regulations being finalized, executives at the top would be responsible for the accuracy for that disclosure. The information would be on a searchable website so the public can check it out. About 1,100 companies would have to file reports.

Every transaction may not be dubious, but when more than one out of four doctors are paid for consulting, lectures or enrolling patients in clinical trials, you deserve to know if your doctor might have a financial interest in a particular company.

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Monday, January 23, 2012

Error Correction Physicians organizations on HCR from 2009/2010

In 2009, I had tracked down the largest medical organizations to determine their position on the then current Health Care Reform Bill, HB 3200. At the time, I reported that 8 of the 10 largest physicians organizations supported HB 3200. I noted at the time: 

For completeness, #8, the American Society of Anesthesiology and #10, the American College of Radiology are still against reform until they get reimbursement "fixes." 
Then, on Nov. 11, 2009,  I wrote:
Now that the American Society of Anesthesiology has voted to support the House Bill, we now have an AMAZING NINE OF of the TEN largest physicians organizations supporting reform.

That, apparently is incorrect, and my colleagues Vivek Murthy and Harold Pollack linked to my post from Feb. 9, 2010, indicating that the ten largest organizations supported health reform with a public option. That last part, I believe, is/was true in that all of those organizations were supportive of the public option (the ASA when reimbursement was delinked from Medicare rates). As my blog post states, 
SO, actually, the BIG NEWS is that 10 of the 10 largest physician organizations support health reform with a public option.

I must have inferred or confused the ASA support with the public option with overall support, and I suspect that this was due to the massive focus on the public option issue at that point in time.

As I look back at the other posts I wrote since then, including the one Vivek and Harold cited, I have an exclamation point beside the ASA, as it surprised me so much. 
But I have spent over an hour looking, and although I found press releases indicating qualified support by the ASA, I cannot find anything indicating unqualified support. And, as they pointed out to Harold and Vivek, they did issue a formal statement against the FINAL reform bill in March, 2010.

BUT, ASA correction noted, nearly all of the major physicians organizations supported the House Bill (which included the Public Option and the SGR fix), and continued to support the final bill, warts and all.

So, my apologies to the ASA and to Harold Pollack and Vivek Murthy. I will go back and note this correction in the old posts.


Christopher M. Hughes, MD

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Saturday, January 21, 2012

25 Best Global Healthcare Rankings

Interesting web site with all these links on International comparative health care. 

25 Best Global Healthcare Rankings: Healthcare Infographics

These interesting infographics help you visualize various healthcare rankings, and can help you see just where your country of residence sits.

  1. Global Health-Care Snapshot: Presents a ranking of countries by how much they spend as a percent of GDP. Includes comparisons of costs in 1980 and in 2006 so that you can see where health care costs have grown the most. Includes helpful information on how people are insured in developed countries, and tabs that illustrate life expectancy and infant mortality.
  2. Health Care Expenditures: An International Comparison: This infographic ranks different expenditures on healthcare by country. Expenditures considered include nursing homes, administration, medications, hospitals and more. An interesting way to break down healthcare costs.
  3. U.S. Healthcare Quality: Get a look at how countries are ranked in terms of health care quality. This infographic looks at different factors related to quality, and ranks different countries.
There are lots more...
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Tuesday, January 17, 2012

France: 'Best' Health Care?

I am taking an International Comparative Health Care Course this semester, so will be adding to my US/World Healthcare Comparison tag I'm sure. Here's a piece from CBS Sunday Morning on France. The second half, showing the EMS triage system is pretty impressive.

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Sunday, January 15, 2012

To Fix Health Care, Help the Poor - NYTimes.com

To Fix Health Care, Help the Poor - NYTimes.com:

IT’S common knowledge that the United States spends more than any other country on health care but still ranks in the bottom half of industrialized countries in outcomes like life expectancy and infant mortality. Why are these other countries beating us if we spend so much more? The truth is that we may not be spending more — it all depends on what you count.

In our comparative study of 30 industrialized countries, published earlier this year in the journal BMJ Quality and Safety, we broadened the scope of traditional health care industry analyses to include spending on social services, like rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support and other services that can extend and improve life.

We studied 10 years’ worth of data and found that if you counted the combined investment in health care and social services, the United States no longer spent the most money — far from it. In 2005, for example, the United States devoted only 29 percent of gross domestic product to health and social services combined, while countries like Sweden, France, the Netherlands, Belgium and Denmark dedicated 33 percent to 38 percent of their G.D.P. to the combination. We came in 10th.

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Thursday, January 12, 2012

Is Medical Student Choice of a Primary Care Residency Influenced by Debt?

Is Medical Student Choice of a Primary Care Residency Influenced by Debt?:

Mean total debt for the study population was $89,807 (SD = 54,925). Graduates entering PC did not have significantly less total debt than those entering NPC ($87,206 vs $91,430; P = .09). Further, total debt was not a predictor of a PC residency after adjusting for medical school, year of graduation, and years of training in residency (P = .64).
And another take, similarly suggests medical school costs as independent of specialty choice. I can imagine several reasons for this, and I think the grand experiment could be somewhat as suggested - try major reductions in specialty income and increases in PC income and see what happens. Only half joking here.

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Friday, January 6, 2012

Parsimony & Medicine

[This is cross-posted on Doctors for America's Progress Notes and DailyKos.]

I wasn't planning on writing about rationing of health care again, since we covered it in my last post prompted by Don Berwick's resignation from CMS.

But two stories came up recently that prompt me to do it again. The American College of Physicians released their revised Ethics Manual this week, and included language regarding the use of cost effectiveness as a criteria for providing care, and even urged parsimony by physicians. In an accompanying editorial, Ezekiel Emanuel, lauds the ACP for this language, noting the physician's obligation to society as a whole, and not just to individual patients. (As we noted last time, the Charter on Medical Professionalism  and the AMA Code of Ethics emphasize the physician's duty to social justice in the distribution of finite health care resources.)

All well and good, but NPR did a story on the Manual, and out it came. Scott Gottlieb, MD, of the American Enterprise Institute noted the general acceptance of cost effectiveness data in medical decision making, but then followed up that parsimony "really implies that care should be withheld. There's no definition of parsimonious that I know of that doesn't imply some kind of negative connotation in terms of being stingy about how you allocate something." (The definition I linked to above notes that parsimony can mean simply being careful with money or stingy.)

Daniel Callahan of the Hastings institute also got the vapors: "If you say certain things will not be cost-effective, they're not worth the money, well that's rationing, particularly if some patients might benefit or simply some might desire it whether they benefit or not, whether it benefits them or not. So that's where this all becomes a real viper's pit."

As we noted previously, America rations health care ruthlessly, largely by income and inability to pay (yes, I know that's a link to an NPR story), but also on quality of insurance, most acutely with private health insurance and Medicaid. I won't run through all of this again, please reread the last post for the details, but I cannot help but find it exasperating that supposedly knowledgeable people, like Gottlieb and Callahan, act as if utilizing cost effectiveness strategies necessarily means "withholding care," and, by extension, that all care, effective or not, cost-effective or not, is beneficial.

But more irksome is the implication that we don't ration now, and that this new, threatened "rationing," is somehow anathema to America. Which brings me to the second story that came up this past week, concerning money troubles in the British NHS and a regression in some areas to longer waiting times for certain procedures. The NHS had done quite a bit to repair their reputation and significantly shorten waiting times, but are apparently losing ground due to governmental austerity measures that (surprise!) actually effect people in real life. I noticed that conservative web site Townhall.com covered the story as an indictment of all health care, all over the world (and, of course, missing the irony that conservative austerity measures were the source of the problem). I pointed out over there with a flurry of comments that we're not so hot on this score ourselves, but also noted that Germany and France, in particular, provide health care for all, far more frugally (parsimoniously, even) than we do, and have no waiting times, no significant rationing of services compared to us. We remain the only industrialized nation that thinks nothing of rationing health care - and I mean this more literally than usual - as many of us give no thought to those struggling and suffering and dying for health care.

A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy--a country that switched to Japanese cars the moment they were more reliable, and to Chinese T shirts the moment they were five cents cheaper--has loyally  stuck with a health-care system that leaves its citizenry pulling out their teeth  with pliers. 
                    - Malcolm Gladwell, The Moral Hazard Myth

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Monday, January 2, 2012

Physicians' Views of the Massachusetts Health Care Reform Law — A Poll — NEJM

Physicians' Views of the Massachusetts Health Care Reform Law — A Poll — NEJM:

Of 2135 practicing Massachusetts physicians who responded to the poll, 70% said they support the Massachusetts Health Care Reform Law, whereas 13% oppose it.

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NHS or US healthcare? | Poll | Comment is free | guardian.co.uk

NHS or US healthcare? | Poll | Comment is free | guardian.co.uk:

Which system would you rather be treated under?

89.9% ---- The NHS, every time

10.1% ---- I'd prefer to avoid the waiting lists and go stateside
 The website TownHall did a piece on a UK-NHS "horror story" and so I comment bombed them with posts on US anecdotes, international health care, and so on. It is amazing what a bubble these people live in. Read the comments and be prepared to bemoan the US educational system and our media environment. All of their prejudices are clearly pulled right out of Fox, IBD, WSJ, and the rest. Heaven forbid actual research.

I also found this poll from a few years ago that I thought was useful.

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