"The Senate will never vote to confirm Dr. Donald Berwick as CMS administrator", Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee told reporters earlier today. According to Modern HealthCAre, Baucus said that he has discussed Berwick's nomination with Republican senators and they plan to oppose Berwick under any circumstances.

“Republicans won,” he said about the nomination. 

 For his part, Berwick told reporters that he was grateful for the White House support he has received since 42 Republican senators wrote President Barack Obama last week to demand that he withdraw Berwick from consideration. Earlier today, Modern HealthCare quoted Berwick saying that he is "focusing on the job."

For Republicans to flatly refuse to consider a presidential nominee without letting him testify at a confirmation hearing signals something far short of "bipartisan cooperation." 

Do they actuallly have that much power? 

Perhaps. But arrogance can be dangerous.

I find it hard to imagine that the Obama administration will roll over and say "Okay. We'll let forty-two senators decide who heads up Medicare." The gang of 42 do not  even represent a majority of the 100 elected representatives in the Senate. But of course, 60 votes would be needed to break a filibuster, which is why the group, led by Sen. Orrin Hatch, believe that they have the clout to pull this off.  

When President Obama named Dr. Donald Berwick to head the Centers for Medicare and Medicaid (CMS) last March, I wrote this:

“Most who know Berwick describe him a ‘visionary’ and a ‘healer,’ a man able to survey the fragments of a broken health care system and imagine how they could be made whole.  He’s a revolutionary, but he doesn’t rattle cages. He’s not arrogant, and he’s not advocating a government takeover of U.S. health care.”

To understand what I meant, view these clips from the film, Money-Driven Medicine, where Berwick speaks about the need for healthcare reform. Soft-spoken and charismatic, Berwick is as passionate as he is original. His style is colloquial, intimate, and ultimately absolutely riveting. He draws you into his vision, moving your mind from where it was to where it could be.

And now, it appears that we are going to lose him. Thursday, 42 Senators delivered a letter to President Obama demanding that he withdraw his support for Berwick to head CMS. The Boston pediatrician and co-founder of the Institute for Health Care Improvement (IHI) had received a temporary appointment in July while Congress was on vacation. President Obama re-nominated him in January. But Berwick still needs to be confirmed by the Senate, or he will have to leave his post at the end of this year.

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It’s always good to hear about the FDA being proactive. Below, a post by Jim Edwards, writing on BNET’s  “Placebo Effect, ” tells how the FDA reacted when surgeons began advising doctors that they shouldn’t use the word “cancer” when talking about a form of breast cancer associated with breast implants.  

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When is breast cancer not “cancer,” not malignant and not a tumor? When you’re a plastic surgeon trade group funded by implant makers Allergan (AGN) and Johnson & Johnson (JNJ), according to an exchange of letters between watchdog group Public Citizen and the FDA.

In January, the FDA warned of an unusual type of breast cancer associated with implants. Allergan, which makes the Natrelle brand of implants, responded by denying that implants were linked to cancer and by denying that anaplastic large cell lymphoma (ALCL) is “cancer” per se.

On Feb. 3, the presidents of two cosmetic surgery trade groups — The American Society of Plastic Surgeons and The American Society for Aesthetic Plastic Surgery held a members-only webinar where they advised doctors on what to say to worried women. Dr. Phil Haeck, president of ASPS, said ALCL wasn’t a “cancer” but a “condition”:

“[Y]es it’s classically a malignant tumor, but it has such a benign course that when we were discussing ways to talk to the media we decided that we would call this a condition  . . .not a tumor, not a disease and certainly not a malignancy. . . .

“And I would recommend that you use the same terms with your patients rather than disturb them by saying  ‘this is a cancer.’   . . .The best word is “this is a condition.’  If you develop this condition here’s how we are going to treat it, the way we are going to diagnose this condition is this . .. .

And I think you are certainly justified, with what we know now, in downplaying the malignant potential of these [cancers].

The FDA responded by having a little chat with the two groups and the video of the webinar has magically disappeared from the groups’ web sites.

Following the money

It is probably not a coincidence that ASPSS and ASAPS repeated the cancer-denial line first promulgated by Allergan: Both organizations have received funding from the company. ASPSS has also received funding from Allergan’s main competitor, J&J, which makes the Mentor implant line. (Mentor’s reaction to the FDA warning was more muted than Allergan’s but its statement also avoided mentioning the C-word.)

Both Allergan and J&J fund provide funds for ASPSS, as noted on its web site.

At ASAPS, Allergan’s funding is more indirect. It has supplied research grants through ASAPS’ research arm, the Aesthetic Surgery Education and Research Foundation. You can see those grant award announcements by searching for “Allergan” here.

The two groups ought to be ashamed of themselves. It is one thing to take funding from drug and device companies . .  . . But the groups ought to represent the medical expertise of the healthcare providers who are their members, not the PR agendas of two companies who are afraid they may lose money from too much blunt but accurate talk about breast cancer.

Roughly 65 million Americans live in places where there are at least 2,000 potential patients for each lonely physician. No surprise, these tend to be impoverished rural regions, or depressed inner cities. We call them “underserved areas.”

If we paid medical schools to train more primary care physicians, would they migrate to these areas? Probably not. Experience shows that if we increase residency slots, physicians continue to flock to the same popular, well-served areas where most prefer to settle: Manhattan, Boston, Boca Raton. . .

It should come as no surprise that relatively few med students elect to set up a practice in rural Mississippi, Detroit, or the South Bronx—unless they are returning home. As I have written in the past, research reveals that students coming from low-income communities frequently feel a commitment to those communities.  

Many—not all, but enough—want to go back. But these days, given the sky-high cost of medical school tuition, combined with the nearly perfect test scores and GPAs that med schools require, very few students who attended public school in a small town in Tennessee wind up becoming M.D.s. 
Yet health care reform guarantees that waiting rooms full of formerly uninsured low-income patients will be looking for health care. According to the Harvard Medical School, an additional 17,000 primary care health professionals will be needed in underserved areas. Skeptics suggest that reformers have promised more than we can possibly afford. How will we funnel more general practitioners to areas where there already are too few physicians? How much will we have to pay to lure them there?

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When I was in my twenties, I was diagnosed with glaucoma. At the time, I didn’t worry about it. I was twenty-something, busy teaching, having babies, writing a book—and, with glasses, my eyesight was 20/20.

It was only when I moved to Manhattan twenty-five years ago that I began to take the disease seriously. A friend recommended an ophthalmologist who, I was told, was one of the best in the city. He regularly turned up on lists of New York’s star specialists, had an office on Park Avenue, and didn’t take insurance of any kind. Twenty-five years ago, this was unusual. But, my employer’s insurance was generous and paid most of his very high fee.

At my first appointment, I mentioned the early diagnosis of glaucoma. After examining my eyes, Dr. X told me that that I must begin using eye drops immediately. I also should begin making appointments to see him every four months so that he could check the “pressure” on my optic nerve. Glaucoma is the second leading cause of blindness in the U.S. There is no cure, but usually it can be controlled with eye drops. “It must be watched carefully,” said Dr. X. 

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This fortnight’s Health Wonk Review is hosted by Louise Norris of the Colorado Long Term Care Insider who has done an excellent job of rounding up some of the most provocative health care posts published in the past two weeks.

Writing on the Incidental Economist, Austin Frakt explains that if we rein in health care spending, we have to go where the money is. And that is not in the health insurance industry. Insurance premiums are so high, in large part, because reimbursements to health care providers have been sky-rocketing, along with payments to drug-makers and device-makers.

“In each of the past 50 years payment to health care providers has accounted for more than 85 percent of health insurance premiums,” Frakt points out. “Thus, only a small fraction of spending on health insurance premiums is consumed as a cost of insurance. I have no doubt that there are ways to squeeze some efficiency out of the insurance system. But doing so is not likely to make a substantial, long-term impact on the inflation of health care costs.

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Over at Kevin M.D., Kevin Pho has raised the possibility that health care reformers who are calling for more “large integrated health systems like the Mayo Clinic or Kaiser Permanente” may wind up creating monopolies that have the market clout to charge more—raising the total cost of health care.

Kevin notes that “according to the Dartmouth Atlas” these large integrated health systems “lead to better patient care and improved cost control. . .  To that end, [the idea of ]Accountable Care Organizations has become a major part of health reform . . . But,” he warns, “the creation of these large, integrated physician-hospital entities that progressive policy experts espouse comes with repercussions.

“Monopoly power.

“To prepare for the new model of health care delivery, physician practices have been consolidating. In many cases, they’re being bought by hospitals. Last year, I wrote how this is leading to the death of the private practice physician.

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Today, close to one-third of all babies born in the U.S. enter the world through a slit in their mother’s abdomen, usually just above her pubic bone. Since 1975, the share of mother who undergo a Cesarean has more than tripled, rising from roughly 10.5 percent to nearly 32 percent according the Public Citizen Research Group, a health care watchdog based in Washington D.C.

These numbers have been widely reported, most recently by Leap Frog, the employer-driven hospital quality watchdog. But a central question remains unanswered: Why are so many more women choosing C-sections? Do they have enough information to make informed decisions? What role do physicians and perhaps, most importantly, hospitals play in C-section rates?

The Link between C-Sections and Induced Labor

Today, more and more expectant mothers are scheduling their babies’ births. Rather than leaving the timing to the whims of Mother Nature, they arrange to have their physicians induce labor; using drugs or mechanical devices to ripen the cervix two or three weeks before their due-date. Over the past two decades, the odds that a doctor will jump-start labor have doubled, rising to 22.5 percent of all births, reports the National Center for Health Statistics (NCHS).

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Below, a guest post from the Center for Public Integrity, one of the country’s oldest and largest nonprofit news organizations. The Center’s mission is to produce “original investigative journalism about significant public issues to make institutional power more transparent and accountable.”  Recently the Center has begun partnering with other news outlets, including the Wall Street Journal, Newsweek and the Daily Beast, to provide the in-depth investigative reporting that the vast majority of newspapers and magazines in our downsized news industry can no longer afford.

Here I am cross-posting a large chunk from a piece which focuses on how “Digital Mammography Saps Medicare Dollars.”  The subtitle reads: “How GE, Others Used Political Muscle, Advertising to Lure Medicare into the New Procedure.” 

For regular Health Beat readers, the second half of the story will be eye-opening. (Scroll down to “A Promising New Technology”).  Most of you know that our health care system  is suffering from what some call “an epidemic” of testing, but few journalists have written about the role that lobbyists for corporate giants such as GE have played in making hospitals feel that they have no choice but to buy exorbitantly expensive, and not always fully tested, medical equipment.

Click on the link to read the full story.

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We all have heard that “spending more” on health care does not necessarily lead to better care. In fact, in regions of the country where care is more intensive and more expensive, sometimes outcomes are worse. This is the basic thrust of what has become known as the “Dartmouth research,” and most medical researchers agree.

But a paper just published in the Annals of Internal Medicine suggests that specific types of higher hospital spending may lead to better outcomes. After examining the records of some 2.5 million patients admitted to 208 California hospitals from 1999 to 2008 a group of researchers from the University of Southern California and Harvard Medical School report that patients who received more costly and aggressive care were less likely to die while in the hospital.

Let me be clear: this study is not trying to prove that the Dartmouth research is “wrong." The investigators, led by John Romley of the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California, begin by acknowledging that “a convincing set of studies demonstrates that U.S. regions that spend more on medical care–using more specialists, diagnostic tests, imaging, and inpatient hospital care–have similar or poorer patient outcomes than areas that spend less. (Here they footnote the Dartmouth Atlas and this article by Dartmouth’s Elliott Fisher, et.al. 

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