Summary: Once again, Health Wonk Review offers a round-up of many of the most intriguing and informative health care posts that appeared during the preceding two weeks. Julie Ferguson, of Workers Comp Insider, http://www.workerscompinsider.com  hosts the most recent edition. She begins with an eloquent riff on the “dog days of summer,” July 24-August 24, a span ancient Romans described as an evil time, “when the seas boiled, wine turned sour, dogs grew mad, and all creatures became languid, causing to man burning fevers, hysterics, and phrensies.”  Ferguson suggests  that the description captures not only this summer’s heat, but the ongoing debate over health care reform.

She then goes on to do a splendid job of highlighting rich, thought-provoking posts that bloggers have managed to pen recently, despite the maddening heat. Below, I offer just a short summary of some of these pieces, along with my commentary. To read the posts in full, go to Ferguson’s Health Wonk Review  http://www.workerscompinsider.com/2010/07/-like-much-of-t.html where you will find links to each post.

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On Managed Care Matters, Joe Paduda congratulates "Several large health insurers [that] have decided it's time to get serious about managing costs. They're introducing plans with limited provider networks and either no coverage for out of network providers or high deductibles and co-insurance/co-pays. The plans, introduced by United Healthcare, Aetna, Wellpoint and others, are currently only available in a few markets as the health plans test market receptivity." 

Most patients like large networks–but they also would like lower premiums. When insurers feel that they must offer large networoks, this means that they have to include the priciest "brand-name" hospitals and well-known doctors located in neighborhoods where overhead is high, which means that fees are higher.  These are not necessarily the physicans who offer the highest-quality care. Sometimes they do; sometimes they don't. Assuming that  the providers in a smaller network are very good –even if younger, less well-known, or located a little further away–I suspect Paduda is right when he predicts that "consumer backlash will be minimal."

Over at the Health Affairs blog, Princeont economist Uwe Reinhardt explains why we don't want more insurers competing in each local market. Large insurers have clout in the marketplace that allows them to negotiate with providers for lower fees. If you break them up, and create a market made up of many smaller insurers, none has the leverage to bring prices down. Moreover, when there are more insurers competing, each has to spend more on marketing, hiking administrative costs–and premiums. The bottom line: the health care market is not like any other market. Competition does not bring prices down.

Writing on Colorado Health Insurance Insider, Louise Norris, co-owner of a small, independent heatlh insurance brokerage in Colorado, observes that "Although the World Health Organization has long stated that  cesarean section rates over 15% do more harm than good, the US currently has a c-section rate of more than double the ideal limit." I would add that in some regions of the U.S., the rate is far higher. Norris lists the many reasons for such a dramatic increase, including the fact that, as some have observed "doctors make a lot more money for doing a c-section, and can do one a lot faster than it takes to wait for a laboring woman to give birth on her own."

Louise offers a rough formula to arrive at a "standard payment for all births, regardless of whether a c-section was performed or not." (The rate would be calculated based on the assumption that it would be safest if rougly 15% of birth were c-sections.) "There would be no financial incentive for doctors to opt for c-sections," she explains, "as they would no longer receive higher compensation for doing so." At the same time, "the tough medical malpractice environment the OBs practice in would likely provide more than enough motivation for them to continue to do c-sections when there was a true medical emergency, despite the fact that they would know there would be no additional compensation for the birth. It seems counter-intuitive," she adds, "to expect doctors to reduce their c-section rates when we're paying them more to perform them.".”

David Williams of the Health Business Blog expresses doubt about the sincerity of Republican objections to sending extra money to the states for Medicaid, but he also offers a suggestion for how the deficit hawks can satisfy their concerns about Medicaid spending. He would cut the Part D subsidy for drugs –preferably by means-testing the program– and move the funds over to Medicaid.

I share his skepticism about the motives of conservative politicians. He is right: they weren’t terribly concerned about the deficit when they voted for the Medicare Modernization Act, corporate welfare for insurers and drug-makers that added “$500 billion or more” to the deficit. Today, they don’t want to help the states with Medicaid because they want to undermine reform.

At the same time, I’m can’t agree about “means-testing” Part D. Medicare enjoys such solid support because it serves all seniors:  poor, middle-class and wealthy. When you begin cutting benefits for wealthier seniors, you risk losing their commitment to the program. At that point, Medicare could all too easily become a “poor program for the poor and the middle-class.

On Health Care Renewal, the indefatigable Roy Poses writes that “the Avandia spin cycle continues, ever after the FDA safety hearings.”  He cites charges that the drug’s manufacturer, GlaxoSmithKline, buried information about the dangers that the drug poses, and that GlaxoSmithKline's forerunner, SmithKline Beecham,  "secretly began a study to find out if its diabetes medicine, Avandia, was safer for the heart than a competing pill, Actos, made by Takeda . . . the  study  provided clear signs that it [Avandia] was riskier to the heart.  But instead of publishing the results, the company spent the next 11 years trying to cover them up."  Meanwhile, Poses observes, “Bloomberg News reported that a former FDA reviewer ‘withheld from regulators a study showing its Avandia diabetes drug may cause heart attacks.’”

Poses finds it particularly disappointing that “formerly prestigious medical societies and disease activity groups are increasingly funded by industry, and increasingly act like industry marketers.  . . . Three influential groups of doctors who treat diabetes urged patients not to stop taking Avandia,” he notes, “saying on Thursday that while news about the controversial drug may be frightening, it would be worse to suddenly stop taking it.

“That is odd,” Poses adds, “given that Avandia has never been shown to improve clinical outcomes for patients with diabetes, and that there are many other drugs that control blood sugar which appear to be safer. But wait, there is more, The Endocrine Society, American Diabetes Association and the American Association of Clinical Endocrinologists worried that patients may be afraid to take Avandia.
'Patients should continue taking all currently prescribed medications unless instructed otherwise by their health care provider,' Dr. Robert Vigersky of the Endocrine Society said in a statement. 'Stopping diabetes medications can cause significant harm and result in higher levels of blood glucose that may cause severe short term health problems and could increase the risk of diabetes-related complications in the long term.'

“Would not it make more sense to advise patients still on Avandia to consult with their doctors urgently about possible alternatives?” Poses asks. “Meanwhile, it does not seem irrational to be afraid of taking Avandia, given the increasing evidence about its harms, and increasing evidence that what we know about its harms may be an under-estimate.

“So I wondered why these august medical societies seemed so unaffected about the doubts about Avandia's safety, and about the evidence offered to support its use that the latest news ought to generate. It turns out that all three of the medical societies get financial support from, — wait for it — GlaxoSmithKline.”

These are just some of the outstanding posts that Ferguson has highlighted in the latest edition of Health Wonk Review. If time permitted, I would write about all of them. Click here http://www.workerscompinsider.com/2010/07/-like-much-of-t.html  to scan other topics that some of the best health care reporters in the blogosphere have tackled over the past two weeks.