This week, Health Beat is hosting “Health Wonk Review,” a biweekly round-up of the best of health policy blogs. Below, snapshots of posts that we found particularly interesting.

–Maggie Mahar and Niko Karvounis

News about Docs

In the past, Roy Poses has posted on Health Care Renewal (here and here) about the little-known fact that medical schools often fail to pay or otherwise reward faculty to actually teach.

Poses, who has a sharp nose for the ironies of our healthcare system, asks a fair question: “Why are medical school faculty expected to teach in their spare time, and spend their working hours …bringing in large amounts of what is euphemistically called ‘external support’” (a.k.a. $$$$) — while faculty in other schools are actually paid for teaching and other academic activities?

In his most recent post on the topic, Poses points to a story from the (Tucson) Arizona Daily Star reporting that University of Arizona Medical College Faculty are “On the Verge of Desperation.”

“Maybe it has something to do with having to do 10 hours a day of clinical work to bring in ‘external funds,’ and then being expected to teach,” Poses speculates. It turns out that U. of Arizona medical faculty are actually supposed to do three things:  provide high-quality teaching, care for a full load of patients (thereby bringing in the money),  and build a competitive research program—all at the same time.

“This looks like another case of mission-hostile management at a well-known medical school,” Poses observes, “albeit one that is probably representative of problems around the US.” 

Offering us a glimpse of how medical students see the world Scott Shreeve of Crossover Health grapples with the crisis in primary care. Speaking first-hand from his experience as a medical student at the University of Utah, Shreeve notes that there were efforts to convince students that primary care was the way to go, but that “both the message and the messengers were unconvincing.”

Why? Because, as many of us tend to forget, doctors are what economists call “rational actors” just like the rest of us. (Other social scientists have some doubts on this matter, but that’s another post).

According to Shreeve, decisions about specializing “came down to what specialty can provide the best outcome in terms of attaining the quality of life, financial security, and career stability students desire  at a price they are willing to pay in terms of years of training, lifestyle, and financial considerations.

“In the end,” says Shreeve, “the current financial system we have in place creates overwhelming incentives to go into a specialty.”

What Shreeve says about weighing lifestyle issues against costs makes sense. But is anyone else distressed that having an intellectual interest in a certain part of the body (the brain, for example), a particular disease (cancer, perhaps) or being drawn to a particular type of patients (children, for instance, or the elderly) never seems to come up as a factor in the decision-making process? 

The U.S. is not the only country suffering from a dearth of docs in some areas. At Canadian Medicine, the blog for Canada’s National Review of Medicine,  Sam Solomon notes
that a shortage of physicians in Quebec stands as an obstacle to a
major health care bill “that would allow doctors in that province to
work in the private sector after they’ve fulfilled a minimum number of
hours in the public system.” Traditionally, Canadian doctors have
operated as public employees, but this bill—unassumingly named Bill
392—would allow Quebec doctors to also practice privately, a major
paradigm shift.

Solomon gives a good overview of the politics surrounding the bill
before noting that it doesn’t really stand a chance, at least in
the near term. The health minister of Quebec, Phillippe Couillard,
“said, in essence, that he’s in agreement…on the philosophy behind the
legislation but that he’s unwilling to introduce mixed practice during
a time when Quebec is suffering from a doctor shortage.”

At the same time, privatization hasn’t been crossed off Quebec’s long-term health care agenda—definitely an issue to watch.

Maybe fewer doctors could spend more time with their patients if
someone like the Institute for Health Care Improvement’s (IHI)
incomparable Dr. Don Berwick helped them re-organize their office. Just back from Dallas, where she attended the 9th annual summit on
Redesigning the Clinical Office Practice,  New America Foundation’s Joanne Kenen reports on the conference on the New Health Dialogue Blog.

The conference, which was run by IHI, focused on how clinicians could
free up time and resources so people get the care they need, when they
need it. Kenen also provides a link to former Gov. John Kitzhaber’s
keynote address. Kitzhaber, who is an M.D. as well as a former
governor, is usually very thought-provoking. I’d like to read that speech.

Jason Shafrin at Healthcare Economist highlights
an interesting new study that shows the impact of the Hawthorne Effect
on medicine. The Hawthorne Effect is based on the idea that a given
activity is performed better, in the short-term at least, when it’s
observed by a third party.

In this study, from a recent issue of the Journal of Health Economics,
researchers observed doctors and found that the latter did indeed
provide higher quality care when being observed, at least for the first
10 observations, after which point quality dips down to its normal
levels.

More importantly, patients notice the changes in quality. Shafrin
quotes the study as concluding that “a 1 percent increase in protocol
adherence [i.e. properly providing appropriate care in a given
situation]…is associated with about a 0.40 percent increase in the
probability that a patient will declare the consultation to have been
‘very good.’”

This finding is important not just for patients, but, as Shafrin
suggests, also for health care reformers, because it provides a
starting point for understanding the answer to this question: “when
regulators or policy makers succeed in improving the quality of care
provided by some doctors, do patients even notice and/or care?” This
study, which shows that third party intervention can improve care, both
objectively and in the eyes of patients, suggests that the answer is
yes. We care about better care. The trick for regulators and reformers,
of course, is keeping improvements sustained in the long-term.

Tier 4 Drugs

Over at Brass and Ivory, Lisa Emrich offers a provocative  round-up
of  responses to Monday’s New York Times story reporting that many
insurers are now insisting that patients suffering from diseases such
as MS, Hepatitis C and some cancers pay a percentage of the cost of
super-expensive drugs. 

Normally patients are asked to pay a flat fee
of $10, $20, or $30, depending on whether an insurer classifies a drug
as tier 1, tier 2 or tier 3. But now patients are forced to pay 20
percent to over 30 percent of the cost of “tier 4” drugs that can cost
$100,000 a year—or more. Emrich presents the full range of responses
coming from MS Bloggers, Health Policy Wonks, and Medical
Professionals.

While some think that “Patients have been shielded from costs far too
long, subsequently leading to an entitlement mentality,” others
sympathize with MS bloggers like Jeri who writes: “I am terrified about
what will happen when this Fingolimod trial ends and I no longer get my
medication for free. I strongly believe that the medicine is the reason
for this long period of remission that I am enjoying, and the health
care system is putting a price on that for me. I know it will be out of
my reach once it has gone to market and I am forced to pay for it."

Meanwhile, at the Sentinel Effect, Richard Eskow quotes
a surprising industry response from Robert Zirkelbach of America’s
Health Insurance Plans: "When plan designs are no longer made to change
behavior, but simply to transfer high-cost items back to the insured
party, that’s risk transfer and not benefit design. As a result, the
insurance concept is being subtly modified – and arguably undermined."
[Note:  this, from an interview by American Prospects’s Ezra Klein.]

Lisa ends by tipping her hat to Merrill Goozner of GoozNews, re-printing Goozner’s post on tier 4 in its entirety.

At Colorado Health Insurance Insider, blogger Louise offers her own very sharp take on tier 4 drugs, and offers her solution for keeping costs down without imposing an unfair burden on a small
group of very sick patients. Her concluding paragraph deserves to be reprinted in full:

“Charging insured [patients] slightly higher prices for common drugs –
the ones that are prescribed to millions of Americans – and not having
to charge dramatically higher prices for the rarely prescribed,
expensive drugs would be a better way of spreading the rising cost of
prescriptions out over the whole population, instead of dumping it at
the feet of those who are already battling against some of the nastiest
illnesses around.” Amen to that.

Finally, for Health Beat’s take on Tier 4, check out Maggie’s last post, where she asks “Who Sets the Price at $100,000” and, does anyone happen to know, “Are These Drugs Effective?”

"When Insurance Companies Go Bad"

If you think insurers who force patients to pay a third of the cost of a $100,000 drug are hard-hearted, consider Joe Paduda’s insightful post on Managed Care Matters, “When Insurance Companies Go Bad.” "Legislators in California are well on the way to passing a law that
would severely restrict health plans’ ability to cancel members’
coverage,” Paduda reports. And it’s about time.

“Over the last five years,” Paduda explains, “about 700 individual
policies have been canceled…with members having little in the way of
formal recourse.” . . . In some cases “individuals with serious health
problems had policies canceled because they did not document minor
health issues that occurred years before the application was filed
(conditions unrelated to the member’s current health problems)

“Even more egregious, at least one payer evaluated, and bonused, a manager in part on her ability to find policies to cancel.”

There are actually two bills in the works, and Paduda gives the
legislation a good chance, pointing out that “one of the bills has
already passed out of the Health Committee on a unanimous vote.”
If it becomes harder for California insurers to cancel policies, the
state’s citizens may well find that, in the future, it will be harder
to get insurance in the first place, Paduda observes—and it could be
more expensive.

Of course he’s right. When insurers are not allowed to shun the sick,
and sick and healthy people are covered in one pool, the healthy pay
more.  That’s the very definition of insurance—“spreading the costs by
pooling risk”—as noted in the posts on tier 4 above.

Paduda blames California’s insurers for over-reaching:  “these bills
never would have come about if certain insurers hadn’t crossed the
stupid line. Here’s hoping other insurers in other states watch and
learn.

Comparative Effectiveness of Drugs and Devices

Many people argue that expensive drugs like those on tier 4 should be
tested against products already on the market. Why pay more for a drug
that is no more effective than what we already have?

But on GoozNews, Merrill Goozner warns
that the “forces of darkness already are gathering to ensure that any
new comparative effectiveness (CE) agency” that the U.S. might create
“remains a ‘toothless tiger.’"

In theory, “it now seems that everyone favors “a comparative
effectiveness agency to help guide practitioners to the best medicine,”
Goozner observes.  “The assumption is that it will cut out some of the
waste in the system (up to 30 percent, if you believe Jack Wennberg and
his Dartmouth colleagues, who put out the Atlas of Health).

“But for comparative effectiveness research to work its magic, the
agency has to be scrupulously independent,” and, as Goozner points out
in "How Not to Run a Comparative Effectiveness Agency, “powerful forces
are already mobilizing to make certain any comparative effective agency
established by Congress” won’t be able to do its job

“When Sen. Max Baucus (D-MT) introduced legislation in March,
Pharmaceutical Research and Manufacturers of America vice president Ken
Johnson  said the agency should be “structured to promote better
patient health and timely patient access to needed therapies, and avoid
denying or delaying patients’ access to beneficial care, as often
occurs in Europe and Australia.”

Of course by “beneficial care” Johnson means what Pharma defines as
“beneficial”—anything that it can sell to the benefit of its
shareholders.

Goozner adds that: “The Advanced Medical Technology Association, which
represents device makers” also wants control over CE findings,
insisting that “governance of any public-private entity should include
representation of all stakeholders.”

What’s wrong with giving drug makers and device makers a place at the
table? “It’s one thing to give stakeholders a chance to advise the
process – just as they have input through comment and testimony into
any regulatory proceeding," Goozner writes. But to allow industry representatives to sit
on the board, and ask clinicians with conflicts of interest to conduct
its studies, would undermine the new agency’s credibility at the start
– and doom it to being just another babbling voice in the health care
wilderness. [my emphasis]

I couldn’t agree more. The U.K. has a CE agency (NICE) that works
precisely because most patients and doctors believe that it is
unbiased. When making a decision, NICE consults with all of the
stakeholders –and their competitors—as well as patients and doctors.
But stakeholders don’t vote and conflicted doctors don’t review the
research.

Speaking of Conflicts of Interest

A new study has been published in the Journal of General Internal Medicine showing  that when clinical trial volunteers are told that an investigator has a financial conflict of interest, that doesn’t seem to affect their willingness to volunteer, reports Daniel Goldberg in a thoughtful post  on Medical Humanities Blog.

This shouldn’t come as a surprise, notes Goldberg, given that many investigators  “actually subject to conflicts of interest labor under fundamental misunderstandings of the way that conflicts actually affect human behavior” believing, for example, “that managing COIs and disclosing them resolves all problems, that individual virtue is proof positive against the behavior-altering effects of COIs.” 
He concludes: “Many participants don’t seem to care much. –well, frankly, neither do many investigators.  But both are mistaken.”

I admit it, as I reach down into the bottom drawer of my desk, I find I’m running out of transitions. So let me just say it. We’re moving on to:

Hospitals—Closing them, Opening them, and Who’s Crowding EDs?

Jane Sarasohn-Kahn provides a crisp and persuasive explanation of “Why It’s Impossible to Close a Hospital” at Health Populi. 

Did you know that “hospitals are the second largest employer in the private sector?”  I didn’t. 

Of course, ultimately, given scarce health care dollars, the point of health care spending must be to improve health, not to create jobs.  Nevertheless, Jane’s entirely right—once the hospital is built, it’s very, very difficult for a community to face losing all of those jobs. I’d say this means we need to think very carefully before letting anyone build a new hospital.

At Physician Entrepreneur, Jose DeJesus MD offers a very different point of view, saying that those who would limit the number of hospitals that are built are “stifling competition” which, he argues, would lead to lower hospital prices. (I’ll believe it when I see it—mm.)

Meanwhile, at Health Access California blog, Anthony Wright calls our attention to an article in the San Mateo County Times which reports that “the proportion of adult ED [emergency department] visits by persons without insurance was stable across the decade," roughly in the 14-15 percent range,” a statistic that Wright notes is actually “lower than the overall percentage of uninsured people in the country, which is around 16 percent.”

Wright also quotes an Urban Institute report that concludes “the uninsured and the privately insured adults have the same risk of being frequent users” of EDs and that “it seems hard to blame the overcrowding of EDs on the uninsured."

At first glance, this may seem a welcome piece of information to those who are concerned with inequality, because it suggests that we can’t pin our high health care costs on an underclass over-using our EDs. In other words, those without health insurance are no longer scapegoats.

But Wright shrewdly points out that those skeptical of universal health care can also make political hay from the numbers by claiming that if those without health insurance aren’t piling into EDs, then their lack of insurance is not a system-wide problem—and voila! No need for health care reform.

Not so fast, says Wright: when the uninsured “finally do go to get care, [they] are in a worse condition since they let their conditions linger and mestatisize.” This ends up “costing the health system more money in the long run,” and also drives up their personal health care costs, which means that “some face bankruptcy not being able to pay, and as a result leave the hospital unpaid.” In other words, Wright is correctly pointing out that even if they are not responsible for crowding our EDs, the fact that there are so many uninsured still costs the system a lot of money.

On Health Business Blog, David E Williams also takes on the conventional wisdom about EDs (among other things) when he asks whether the statements below are true or false:

1.    It’s less expensive to pay for prevention than to pay for treatment
2.    The US spends less on prevention than other rich countries
3.    Emergency rooms are overcrowded because that’s where uninsured patients go for care
4.    Universal coverage will pay for itself by shifting the uninsured from the emergency room to primary care physician offices.

Then he gives you his answers: “You wouldn’t know it from the candidates or even based on common sense, but all of these statements are false.” 

Disease Management

Merrill Goozner mentioned the “Dartmouth Research” which has shown how much waste there is in our health care system, and over at the Disease Management Care Blog, Jaan Sidorov discusses the latest addition of the Dartmouth Atlas, which uses Medicare claims data to map variations in health care and health outcomes across the country.

Jaan points out that while Wennberg and co. do note that medical homes represent a potential benefit for those with chronic diseases, they suggest that we may not be ready for medical homes just yet. For the medical home model to be successful, “the primary care physicians would need to assemble into networks” and then “they’d need to be willing to profile hospitals and use the data to steer patients.” 

Sidorov’s not trying to bash the medical home idea, but he wants to call attention to another critical issue—disease management—which actually gets more airtime in the Dartmouth report, but has gotten less attention from commentators reacting to the newest Atlas.

Sidorov grabs meaty quotes from the most recent edition of the Atlas to show that the Dartmouth team treats disease management with fewer qualifications and strongly supports “the established positive role of disease management in the care of chronic illness.” As such, says Sidorov, we should all “hope the politicians, regulators, policy makers and industry leaders closely read the entire document” so that the importance of managing chronic diseases is not overlooked.

Finally, two more posts: one about New Jersey, the other reporting on the state of the world.

Dear Governor Corzine…

At Worker’s Comp Insider, Jon Coppelman takes a hard look at New Jersey’s workers comp system, noting that the Garden State is “is operating in the darkest of dark ages” thanks to “inordinate delays in the provision of benefits,” the absence of a system to “determine whether injured workers are receiving the benefits they need,” and the ubiquity of “political patronage” that helps inflate an already inflated “bureaucratic structure that makes New York seem streamlined.”

Coppelman discusses two tragic examples of the system’s failure, including the story of “John DeJulio, a retired veteran working at Home Depot” who slipped on a puddle, broke his leg, and not only had to wait “more than three years to secure approval for knee surgery” but “had to see five specialists and attend nine court hearings before the surgery was approved.” Yikes.

Coppelman also notes that NJ has its own systemic peculiarities that results in a volatile benefits system (sometimes generous, sometimes stingy) and an opaque bureaucracy of workers comp decision making—a state of affairs that pleases employers, because “it is reasonably cost effective,” but is unfair to injured workers, “who can encounter considerable difficulty in securing the benefits they need to stay afloat.”

Last, but hardly the least important topic: Climate Change

David Harlow’s HealthBlawg recently welcomed readers to the World Health Day edition of Blawg Review,  offering links to posts from the World Health Organization, the EPA’s proposed methodology for measuring greenhouse gas emissions, the Warming Law blog (which isn’t happy with the job the EPA is doing), Al Gore’s new advocacy campaign on climate change–and responses to it. And that’s just the beginning of Harlow’s round-up.