“Divide and Conquer” is a strategy that has served conservatives well over the years. Remind younger Americans that their elders are “greedy geezers.”  Set the middle-class against the poor, by telling tall tales about welfare queens. Pit the native-born against new immigrants.

And now, Rep. Paul Ryan’s (R-WI) plan for Medicare draws a bright line between Americans over 55 and those who have not yet reached that turning point in their lives. As I explained in an earlier post, Ryan would give folks in that younger group a voucher when they retire, send them out into the private sector to buy their own insurance, and wish them good luck keeping up with health care inflation. Those over 55, on the other hand, would be allowed to keep the federal program that guarantees their care. For once you may think, it pays to be older.

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A headline in last week’s New York Times suggested that, at last, conservatives and liberals have found an issue that they can agree on: “Obama Panel to Curb Medicare Finds Foes in Both Parties,” the story announced, referring to the Independent Payment Advisory Board (IPAB) created by the Accountable Care Act (ACA) to monitor and curb Medicare inflation. The article quotes both Democrats and Republicans warning that the panel is, in fact a “rationing board” made up of “unaccountable bureaucrats” who threaten to “endanger patient care.” While spotlighting the board’s opponents, the Times quotes only one Democrat who supports the bill: Senator John D. Rockefeller IV, (D, W.VA), the chief architect of IPAB. One is left with the impression that legislators have found a righteous bipartisan cause, and that the IPAB is likely to be repealed.

Then, there are the facts:  Exactly four Democrats have signed on to Rep. Phil Roe's (R-Tenn.) IPAB repeal bill:  Reps. Shelley Berkley (D-Nev.), Michael Capuano (D-Mass.) Larry Kissell (D-N.C.) and Rep. Allyson Schwartz (D-Pa)  Meanwhile, in his recent speech on the deficit, President Obama made it clear that that he has no intention of eliminating the board; to the contrary, he hopes to strengthen IPAB. Any legislation that attempts to kill or seriously weaken the Independent Payment Advisory Board faces a certain veto. In other words, reports that IPAB is about to be repealed are greatly exaggerated—as are suggestions that IPAB poses a threat to Medicare beneficiaries.

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While markets may lack the rational intelligence needed to become the “invisible hand” that guides constructive change, free markets (and the shrewd marketing experts that corporations employ), can be quite astute when it comes to responding to changing trends. This is, after all, a matter of survival.  If they don’t get ahead of the trend, they risk a rendezvous with a moving train.

Although members of the American public may not be at all certain what the Affordable Care Act will mean for them, insurers, hospitals, drug makers and device makers have made it their business to read the legislation carefully. These companies realize that it would be reckless to assume that the legislation will be repealed:  their competitors already are preparing for change. Thus, market-watchers say that in the medical marketplace, reform is becoming a reality as the health care industry implements fundamental changes in insurance coverage, access, payment, and how health care is delivered.

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A licensed social worker with a master’s degree earns less than a manager of a fast-food restaurant, according to the 2011 Behavioral Health Salary Survey just released by the National Council for Community Behavioral Healthcare. The survey finds that the nation’s mental health and addictions treatment professionals are paid far less than their counterparts in other health care sectors.
 
“Just as people with mental illnesses and substance-use disorders are routinely stigmatized, it appears those working in the behavioral health sector are also treated differently—even within the health care community,” says Linda Rosenberg, National Council president and CEO.

Why the stigma? A few reasons come to mind.

Some people believe that it isn’t worth spending much on caring for and counseling the mentally ill because “they’ll never  be able to make much of a contribution to society.” (I recall an attorney who was defending a city that refused to follow state laws about educating and mainstreaming handicapped children explaining to me that:  “These kids will never get good jobs and pay enough in taxes to return on the investment the city would be making in their education.” )

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Over at GoozNews.com, Merrill Goozner raises a very good question. Under the headline “SEC Slaps J&J with $70 Million Penalty for Overseas Corruption” Merrill asks: “What’s the difference between what the medical supply company did abroad compared to what it or companies like it do every day in the U.S.?”

My response would be “not much”—except that U.S. patients are the victims when these companies bribe our physicians.

Goozner continues: “Forget for a moment that Johnson & Johnson was also accused of paying kickbacks to the Iraqi government to illegally obtain business. The Securities and Exchange Commission’s main charge accused J&J of “bribing public doctors in several European countries.”

“Here’s how the press release described the violations:

“Since at least 1998, subsidiaries of the New Brunswick, N.J.-based pharmaceutical, consumer product, and medical device company paid bribes to public doctors in Greece who selected J&J surgical implants, public doctors and hospital administrators in Poland who awarded contracts to J&J, and public doctors in Romania to prescribe J&J pharmaceutical products.

“Moreover, according to the SEC’s complaint filed in federal court in the District of Columbia, public doctors and administrators in Greece, Poland, and Romania who ordered or prescribed J&J products were rewarded in a variety of ways, including with cash and inappropriate travel. Another violation: J&J subsidiaries, employees and agents used ‘sham civil contracts’ with doctors.

“These wouldn’t be consulting agreements, would they? I fail to see how J&J’s actions abroad in these particular aspects of the case were any different from what makes the front page of the New York Times and the Wall Street Journal every couple of months with regard to payments to U.S. physicians for attending dinners and lectures, installing preferred medical devices, and offering sham consulting agreements. In 2007, the government brought a major case against five device companies that temporarily cracked down on these practices. A week ago, a front page story told us these practices continue unabated at least one major U.S. hospital. Where are the ongoing investigation indictments in those and other cases?”

Read the rest of Goozner’s post–and see his recommendation that we pass a Corrupt Domestic Practices Act. 

Below, a Guest Post by Dr. Nortin M. Hadler, Professor of Medicine and Microbiology/Immunology, University of North Carolina at Chapel Hill and Dr. Robert A. McNutt,  Professor of Medicine, Chief,  Section on Medical Informatics and Patient Safety, Rush University Medical Center, Chicago.  Their argument that comparative effectiveness research (CER) needs an “anchor”—one treatment with known efficacy—is a good one, and gave me a new perspective on CER. In their analysis of randomized controlled trials, they highlight the crucial question: how high should we set the bar to consider the results of the trial compelling?

                                              ABSTRACT

“Comparative effectiveness research” is now legislated as a priority for translational research. The goal is to inform decision making by assessing relative effectiveness in practice. An impressive effort has been mobilized to target efforts and establish a methodological framework. We argue that any such exercise requires a comparator with known and meaningful efficacy; there must be at least one anchoring group or subset for which a particular intervention has reproducible and meaningful benefit in randomized controlled trials. Without such, there is a likelihood that the effort will degenerate into comparative ineffectiveness research.

As charged in the American Recovery and Reinvestment Act, the Institute of Medicine defined comparative effectiveness research (CER) as “ …the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat and monitor a clinical condition, or to improve the delivery of care… at both the individual and population levels.”

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Yesterday, on “CNBC’s Morning Joe,” Paul Ryan claimed Alice Rivlin, Clinton’s OMB director, as an ally: “Alice Rivlin and I designed these Medicare and Medicaid reforms” he announced.  “Alice Rivlin is a proud Democrat at the Brookings institution. These entitlement reforms are based off of those models that she and I worked on together.”

I have followed Rivlin’s career since her days in the Clinton administration, and always admired her intelligence, honesty and integrity. To say that I was dismayed to hear that she had teamed up with Ryan to endorse his plan to end Medicare is an understatement.

But last night, Politico.com’s Meredith Shiner reported that in an interview with POLITICO, Rivlin revealed that she has told Ryan that she “cannot support the final version of the [Medicare] measure” that he has been advocating .

“We talked fairly recently and I said, ‘You know, I can’t support the version that you have in the budget,” Rivlin told POLITICO. “I don’t actually support the form in which he put it in the budget.”

When informed that Ryan had used her name to advocate his plan, Rivlin replied: “That’s not quite fair. We had worked together but the version that’s in the budget resolution is not one that I would subscribe to.”

She went on to explain that a plan that she would back would “let seniors have the choice between keeping their current form of Medicare or choosing to enter the [private insurance pool that Ryan calls for.] “I prefer keeping the old version as a choice,” Rivlin said.

POLITICO reported that “The other main difference is in the rate of growth in subsidies for beneficiaries entering the new exchange system: “In the Ryan version, he has lowered the rate of growth and I don’t think that’s defensible,” Rivlin declared. “It pushed too much of the cost onto the beneficiaries.” 

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At last, someone is announcing a Health Information Technology (HIT) initiative that opens the door to efficient, secure IT systems that will be able to talk to each other nationwide. At some point in the not-too-distant future, if you live in Pennsylvania and are in a terrible car accident in California, a Kaiser hospital on the West Coast will be able to tap into your medical records at Geisinger and capture information about your medical history, allergies to certain medications, and other critical information in less than a minute.

Already, thanks to the steps that Kaiser Permanente in California has taken, if you live in the San Diego area, are admitted to a Veterans Administration (VA) hospital, and visit your Kaiser physician when you are discharged, with your permission, he can view your VA records, finding all of the information he needs about results from tests done at the VA hospital, what drugs VA doctors prescribed, and recommendations for follow-up treatment.

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Below, a Kaiser Health News column by John E McDonough, a professor at the Harvard School of  Public Health and a former staff member at the U.S. Senate Committee on Health, Education, Labor and Pensions. I agree with McDonough: health care reform is happening, and it is “energizing the U.S. heealth care system–driving the most vibrant reform atmosphere ever.”

As reform becomes a reality, it becomes harder to repeal. This makes the debate in Washington become less and less relevant. The only major threat to reform: the possibility that a anti-reform president will be elected in 2012.  But by then, so many pieces of reform will be in place that it will be very difficult to eliminate benefits that are helping American families.

I disagree only one point: #7.  I’m afraid we’re in the middle of a double-dip recession. On the other hand, a weak economy makes it all the more apparent that we need health care reform.

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Representative Paul Ryan (R. Wisconsin) thinks he has found a solution to Medicare inflation. 

The cost of Medicare has been spiraling for years, thanks to the climbing cost of virtually every product and service in our health care system.  In other sectors of the economy, competition brings prices down. But when it comes to healthcare, each year, we pay more for virtually every test and treatment. Meanwhile, doctors and hospitals do more. Inpatients stays are shorter than they once were, but as Dartmouth’s Dr. Elliot Fisher puts it “more happens to you while you’re there.” 

Now, finally, we have health reform legislation that is designed to rein in costs by changing how we pay for care, and how that care is delivered.  Rather than rewarding providers for “volume” by paying fee-for-service, Medicare will be rewarding them for “value” in the form of better outcomes at a lower price. The Affordable Care AcT realigns financial incentives, reducing payments to hospitals with the highest rates of errors and infections, while paying bonuses to physicians who create medical homes than manage to keep chronically ill patients out of the ER–and out of the hospital. Hospitals and doctors who collaborate to create accountable care organizations will be able to share in the savings if they squeeze some of the waste out of the system and provide, safer, better-coordinated care. Many communities already have shown how this can be done. 

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