Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker

Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker:

A damning look by Atul Gawande at the way we pay for medical care in America. The final three paragraphs of this must read article.

"Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.

"In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”

"As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future."

I went to the Dartmouth Atlas web site myself and found this interesting tid-bit:

I think it fits in well with the ethos described in Gawande's article.

It is much easier to continue aggressive treatment rather than spend time having an honest discussion about the benefits and burdens of continuing treatment.


Thanks to whoever put the link up on the Howard Dean Webinar tonight!



UPDATE: This recent Archives of Internal Medicine article is particularly apporpriate:
http://archinte.ama-assn.org/cgi/content/short/169/10/954

This also, perversely, can make the hospital statistics in mortality look good, as well. As an intensivist, I can get almost ANYONE out of the the ICU and subsequently out of the hospital if I ignore the true outcome for the patient and the family: additional suffering, minimal prolongation of a life at its end, and so on.

My colleagues who do practice best EOL practices know that our ICU and hospital mortality numbers suffer, but I have no doubt that having honest discussions with my patients and families is the right thing to do. You may have heard this for your patients, “Thanks for the straight talk, Doc,” or “Nobody talked to me about my prognosis before.”

Of course, this is not new information, but we still need to do better as physicians:http://www.chestjournal.org/content/128/1/465.full?ck=nck

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QUALITY: Doctors Oppose Insurer Control Over Patient Care Decisions | New America Blogs

QUALITY: Doctors Oppose Insurer Control Over Patient Care Decisions New America Blogs:

"Some doctors have decided they are fed up and not going to take it any more.California pain specialist Dr. Bradley Carpentier is among them.

"While Republican strategists stir up fears about government meddling in health care, the San Francisco Chronicle reports on doctors like Carpentier who are concerned about insurance companies that come between them and their patients."

Go read the rest.

The EMC Research Study is here.

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Missoulian: Single-payer mentions draw cheers at Baucus-sponsored health care talk

Missoulian: Single-payer mentions draw cheers at Baucus-sponsored health care talk

The hearing ranged broadly over the possibilities for reform, but what clearly resonated for McArthur was something Baucus' chief of staff, Jon Selib, said a couple of times.

Discussing why a single-payer system of health insurance wasn't viable, Selib made reference to the more than 150 million Americans who are covered by some sort of employer-provided health care.

“A lot of people like that,” Selib said.

When the time came for questions, McArthur stood up and asked a simple question. Looking across a standing-room-only crowd of about 275, he asked how many were happy with their employer-based health insurance.Less than 10 people raised their hands.

“The number is bogus,” McArthur said. “It's not working for 95 percent of us.” McArthur drew resounding applause.

In fact, any mention of single-payer health care insurance brought raucous cheers and clapping.

Any other solution to health care reform - including Baucus' “balanced” plan that would create a mix of public and private plans - was received more coolly.

Tuesday's session was one of a handful of events Baucus is sponsoring around the state this week. He chairs the Senate's powerful Finance Committee, and is the point man on health care reform.

He did not attend Tuesday's meeting, but Selib did, and he heard what the senator himself has heard since he announced that single-payer wasn't really on the table.

As Selib worked to massage that point, one man barked out, “Oh bull----.”

Tom Roberts, president of the Western Montana Clinic and moderator at the session, asked the crowd to be civil, but the man had made his point.

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What's on my MP3 Player...

...aren't I cool?

Center for American Progress Events (Audio):


Can Health Reform Deliver for Providers?
Tuesday, April 14, 2009, 5:13:49 PM
Half-way through this and it's very good. Dr. Paulus of Geisinger is very impressive..

Medicare’s Lessons for Health Reform
Thursday, April 02, 2009, 1:04:18 PM

Health Reform: “Now is the Time for Action”
Friday, March 27, 2009, 10:59:49 AM
This features Sen. Baucus as opener, then has some good discussion with Paul Begala and Norm Ornstein and Karen Tumulty...

The Ideology and Politics of the Millennial Generation
Wednesday, May 13, 2009, 1:10:51 PM

"The Age of Stupid"
Wednesday, April 29, 2009, 12:12:33 PM

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Health Reform Without a Public Plan: The German Model - Economix Blog - NYTimes.com

Health Reform Without a Public Plan: The German Model - Economix Blog - NYTimes.com:

"What if that [public option] plan were sacrificed on the altar of bipartisanship? Would it be the end of meaningful health reform?

"Not necessarily, if the health systems of the Netherlands, Germany and Switzerland are any guide.

"None of these countries uses a government-run, Medicare-like health insurance plan. They all rely on purely private, nonprofit or for-profit insurers that are goaded by tight regulation to work toward socially desired ends. And they do so at average per-capita health-care costs far below those of the United States — costs in Germany and the Netherlands are less than half of those here."

When I get in discussions of HC reform with my friends who are more committed to a single payer solution than I, I point out that most countries we look to as exemplars of excellent universal health care do not, in fact, use the single payer model, but use some hybridized form of the Bismarckian, or Social Health Insurance model, such as Germany. This may explain why the American College of Physicians made its policy recommendations in 2007: though single payer was recommended first, a hybrid system was neck and neck and felt to be more achievable.

Dr. Reinhardt explains the overview beautifully here, and I cannot improve upon it. He, as always, provides great framing to his points that can be appropriated for the discussions you have on the topic. For more details on the German system, go here.

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Arch Intern Med -- Abstract: Discussions With Physicians About Hospice Among Patients With Metastatic Lung Cancer, May 25, 2009, Huskamp et al. 169 (10): 954

Arch Intern Med -- Abstract: Discussions With Physicians About Hospice Among Patients With Metastatic Lung Cancer, May 25, 2009, Huskamp et al. 169 (10): 954:

"Background Many terminally ill patients enroll in hospice only in the final days before death or not at all. Discussing hospice with a health care provider could increase awareness of hospice and possibly result in earlier use.

"Methods We used data on 1517 patients diagnosed as having stage IV lung cancer from a multiregional study. We estimated logistic regression models for the probability that a patient discussed hospice with a physician or other health care provider before an interview 4 to 7 months after diagnosis as reported by either the patient or surrogate or documented in the medical record.

"Results Half (53%) of the patients had discussed hospice with a provider. Patients who were black, Hispanic, non-English speaking, married or living with a partner, Medicaid beneficiaries, or had received chemotherapy were less likely to have discussed hospice. Only 53% of individuals who died within 2 months after the interview had discussed hospice, and rates were lower among those who lived longer. Patients who reported that they expected to live less than 2 years had much higher rates of discussion than those expecting to live longer. Patients reporting the most severe pain or dyspnea were no more likely to have discussed hospice than those reporting less severe or no symptoms. A third of patients who reported discussing do-not-resuscitate preferences with a physician had also discussed hospice.

"Conclusions Many patients diagnosed as having metastatic lung cancer had not discussed hospice with a provider within 4 to 7 months after diagnosis. Increased communication with physicians could address patients' lack of awareness about hospice and misunderstandings about prognosis."

First, having these conversations with patients is the right thing to do for a multitude of reasons, not the least of which is our duty to help our patients weigh the benefits and burdens of medical treatment. The reduction of unwarranted suffering is hard to over estimate.

Second, imagine the economic impact of doing the right thing. No rationing, just having the appropriate conversations with our terminally ill patients.

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Why is single-payer health care off the table? -- themorningcall.com

Why is single-payer health care off the table? -- themorningcall.com:

"As an advocate for the Pennsylvania Council of Churches, I am charged to advocate on behalf of a single-payer system -- a system I support personally, as well. The council has taken this position because it is the only system that meets all the criteria outlined in our health-care position statement: health care that is universal, continuous, affordable to individuals, families, and for society, and able to enhance health and well-being by promoting access to high-quality care. Despite polling data that consistently shows more than 50 percent support for a national plan or at least coverage for emergencies, we continue to see this option shunned.

"Now, even the prospect of a public option is disappearing before our eyes. How many more people must die, suffer permanent damage because a system has failed them, lose their homes or be driven into bankruptcy before our elected officials will reject complicity in a system that lines the pockets of the few to the pain and detriment of the many? "

[The Rev. Sandra L. Strauss is director of public advocacy for the Pennsylvania Council of Churches, with offices in Harrisburg.]

And the PA Council of Churhes weighs in via an op-ed in the Allentown Morning Call.

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