J. D. Kleinke is a medical economist, author, and health information industry pioneer, and the author of a new book, Catching Babies.

Over at The Health Care Blog, he has published one of the best essays I have ever read revealing “how little obstetricians really know – and how limited the specialty is in its ability to test and expand that knowledge – thanks in part to the visceral fear inspired in patients by statements like ‘a normal pregnancy is a retrospective diagnosis.’”

While protecting the name of his sources, he describes what happens when “Hannah’s” labor does not proceed as quickly as expected:

“Hannah is starting to weary of the process, and she’s hungry; they have put her on a restrictive diet, of course, assuming she will soon go into labor and deliver. When her blood sugar starts dropping, they let her go back on solid food. Her energy picks up, enough to start arguing that maybe she should just go home and wait. ‘Maybe this is a sign that Sam is fine,’ she says, ‘and he just doesn’t want to be born yet.’

“The Kaiser people get wind of our conversation when they walk in to check her IV, and send in the CNM who has just begun her shift.

“She runs through the same argument that had brought Hannah in two days earlier “This time, Hannah argues back.

“’Do you know what could happen, if you wait?’ the CNM finally says with an impatient sigh. ‘Your baby – he could be – stillborn.’”

What can Hannah say?  She is put through the agony of an induced labor:

“The artificially induced contractions are severe, throwing her from the bed. The pain is too intense, and Hannah finally relents and agrees to an epidural, which will numb her from the midsection down and cut her off from the core sensations of the birthing process . . .”

Read the entire post here.

Health care information technology [HIT] “is not ready” warns Dr. Scot Silverstein, a clinical IT expert on the faculty at Drexel University’s College of Information Science and Technology. Writing on Roy Poses’ Health Care Renewal at the end of last week, Silverstein argued that Health IT “is dangerous in unqualified hands, which most every medical center and physician office is in 2011 (i.e., an IT backwater).

“The field of health IT [has] somehow [been] transformed from an experimental field into the 'savior of medicine’” Silverstein added, “without the proof of value and safety that would ordinarily be required to move an experimental technology from lab to national rollout. Per the Washington Post, this process appears to have been a highly politicized one, favoring the corporate elites. The Washington Post’s 2009 article on the influential HIT vendor lobby ‘The Machinery behind Healthcare Reform’ is at this link.”

Set Silverstein’s words side by side with what software expert Dan Fornes had to say on The Health Care Blog yesterday, where he reported that vendors selling health care software are “spending like crazy,” and a larger picture begins to emerge.

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Amy Berman tells her story here, on the Health Care Blog. http://www.thehealthcareblog.com/the_health_care_blog/2011/01/can-good-care-produce-bad-health.html#comments

Her courage and eloquence are remarkable. Facing death, she is able to express her concern for other patients. 

If you or anyone you know is struggling with cancer, you might find this post helpful.

I may be more optimistic than Harold Pollack that the Affordable Care Act (ACA) will reduce ER use (see Pollack's guest post). After all, the ACA provides an additional $11 billion in funding for Federally Qualified Health Centers (a.k.a. “community clinics.”) Many are open after hours, and as existing community clinics are expanded and new ones are built, they could serve as medical homes for patients who now get their care at their local emergency room. This year alone, the ACA will provide a 50 percent increase in federal support for these clinics where patients can receive less expensive, preventive and primary care. (It’s worth noting that the government has already begun to distribute this money; this is just one example of many programs that cannot be “de-funded.”) The legislation also permanently authorizes the community health center program, which once had to be reauthorized every five years.

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In his State of the Union speech, President Obama devoted only a few minutes to health care reform. This might surprise some, but I think the president made a wise decision. There was little reason for him to spend more time on the issue. The Patient Protection and Affordable Care Act (PPACA) is  now the law of the land. There is no reason for the President of the United States to debate it.

President Obama did allow that “anything that can be improved in the legislation” should be changed. I agree. As the law is implemented, experience will show us where adjustments should be made. 

Extending a hand across the aisle, the President also said that “we can start now by reducing unnecessary bookkeeping burdens on small businesses,” referring to the provision  in the heallth care reform legislation which requires that every business provide a 1099 for each vendor with whom it does more than $600 worth of business over the course of a year. This was a provision tacked onto the heath care bill, designed to reduce tax fraud. I applaud the motive, but when it comes to reforming health care, this is not an important plank in the legislation.

More importantly, President Obama made it clear that he would not bow to any effort to undermine the individual mandate: “What I am not willing  to do,” he declared, “Is to go back to the days when insurance companies could deny patients because of pre-existing conditions."

President Obama is confident about the Affordable Care Act because he knows that, this year, health care reform already has begun to deliver benefis to a great many Americans:

— Small business owners are taking advantage of the tax credit and signing up for insurance for their employees

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Below, a guest-post by Dr. Nortin Hadler, author of Worried Sick: A Prescription for Health in an Overtreated America and , more recently, Stabbed in the Back: Confronting  Back Pain in an Overtreated Society. I admire both books because they are so well-written and richly referenced..

Hadler is Professor of Medicine and Microbiology/Immunology at the University of North Carolina at Chapel Hill and Attending Rheumatologist at the University of North Carolina Hospitals.

His commentary on “The Predicament of Backache” is adapted from, Stabbed in the Back. It  puts my posts on spinal surgery in a larger context, illustrating how “cutting” is not always a cure for life’s problems                     

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To live a year without a backache is abnormal.  Here, I am speaking of the commonest form of low back pain: the backache that bedevils working-age adults who are otherwise totally well. This is a pain that does not involve the legs, and that comes on suddenly, seemingly without cause.

Low back pain is one of many recurring predicaments of life, like heartburn and heartache. To be well is not to be spared. To be well is to have the wherewithal to cope till the pain goes away, cope so well that the episode is not even memorable.

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Summary: In part 1 of this post I discussed how the mainstream media has begun the work of health care reform by making the public aware of the amount of waste and hype in the system. There, I focused on two recent stories about back surgery: the first appeared in the Wall Street Journal, the second on Bloomberg. Both tell the tale of patients injured and billions of health care dollars squandered when patients suffering from back pain caused by “degenerative” (aging) spinal discs undergo a very pricey procedure called “spinal fusion.” 

As I explain in part 1, medical research shows that when back pain is caused by aging discs, fusion is not as effective as other, less lucrative, treatments. And, with fusion, the rate of serious complications is much higher. Nevertheless, from 2002 to 2008, the number of fusions done in U.S. hospitals doubled to 413,000, generating $34 billion in health care bills. In 2008, Medicare alone laid out $2.24 billion for the procedure.

Meanwhile both Bloomberg and the WSJ reported that device-makers such as Medtronic, which makes products used in spinal fusion, have been handing out millions in royalties and “consulting fees” to surgeons who promote the procedure. Congressional critics charge that in many cases, these payments are nothing more than “kickbacks."

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This week, Managed Care Matter’s Joe Paduda hosted Honk Wonk Review’s  regular summary of particularly provocative health care  posts that appeared in the past two weeks.  As always, Paduda’s insights make the Review well worth reading.  (I also recommend Managed Care Matters as a blog where you’ll find very smart, objective, fact-based commentary on a wide variety of issues.)

Below, I comment on some of the posts in this week’s Review, but to read the entire round-up (and to find links to posts I mention below)  please click here.  http://www.joepaduda.com/archives/002013.html

Perhaps the most intriguing post in this week’s round-up comes from HealthCare Renewal’s Roy Poses. An M.D., Poses also has become a relentless investigative reporter, and in this piece he discusses “the fall of an apparently large and prestigious health care charity, which funded research projects at the most well-regarded academic centers – a charity that was involved with Bernie Madoff and some of his confederates.”

If you read Poses’ post (and I urge you to do so) you’ll discover that the charity in question–the Picower Foundation–was not quite what it seemed.

In 2008, Poses observes, both the Boston Globe and the New York Times lamented the fact that the Picower Foundation, which had become one of “Maddoff’s victims” was shutting down. Apparently their reporters hadn’t Goggled “Picower.”  Poses calls attention to a more recent Wall Street Journal piece that raises some troubling questions. 

Poses then takes us back to a 2001 St Petersburg Times expose of the Picower Foundation “which suggests that its Jeffrey Picower used it in a complex scheme involving self-dealing for the purposes of personal enrichment.” 

He ends his tale by asking: “The big question is why people can be so easily fooled? 

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In an Opinion column on CNN, Dr. H. Gilbert Welch, M.P.H., a professor of medicine at the Dartmouth Institute of Health Policy & Clinical Practice and the author of Overdiagnosed: Making People Sick in the Pursuit of Health" (Beacon Press 2011), raises questions about a new simple blood test that is
“able to detect minute quantities of cancer cells that might be circulating in your bloodstream.”
Below just a few lines from the column that I found particularly provocative.  You can find the entire op-ed here.
(Thanks to Dr.Val and Gary Schwitzer for spotlighting this column.)  
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“The conventional wisdom is people either have a disease or they do not. But, in fact, there are a lot of people somewhere in between. . .

“I don't know whether this test will help some patients. It might, but it will take years to figure that out…"

“Ironically, what this test might actually teach us is that it's not that unusual for healthy people to have an occasional cancer cell in their blood.”

Hackles rise and fur flies. As Maude Beelman, Deputy Managing Editor at the Dallas Morning News, explains in an essay cross-posted below, local newspapers have good reason to be wary of investigating their community’s most prestigious medical centers:

“Every place has its sacred cows,” she writes in a piece published on the Nieman Watchdog website, “individuals or institutions so prominent and respected that over time they become part of a community’s identity and culture. Questioning them is an affront to civic pride, and investigating them can be a high-stakes gamble.

“The University of Texas Southwestern Medical Center and Parkland Memorial Hospital are two such icons of Dallas,” she continues. “They have enjoyed largely positive press, some of it by design. Their leaders cultivated national profiles and courted some of the wealthiest and most influential Dallas residents, including media leaders, as advisers and donors.”  (Many thanks to Gary Schwitzer at HealthNewsReview Blog, for calling attention to this story.)

So when the Dallas Morning News decided to follow up on insider tips alleging that patient safety was being compromised at these venerable  institutions, the newspaper “faced a community backlash, including cancellation of advertising by UT Southwestern,” Beelman reports.  “Many of Dallas’ wealthiest and most powerful residents are longtime donors and supporters of the medical center and hospital. Some key players have sought to delay, if not derail, the investigation. They have recruited key opinion leaders in Dallas and nationwide to try to discredit us.”

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