Wishful thinking leads many well-meaning reformers to imagine that we can accomplish universal coverage in a single stroke. Writing in the December 31 edition of the New Republic,  political scientist Jacob Hacker suggests that by declaring “healthcare for all” we can achieve universal coverage and , simultaneously,  kick-start the economy.  How do we do it?  Easy—just spend as much money as possible as quickly as possible.

“In fact,” Hacker writes, “we have a magic bullet.”

This sentence stopped me. To my mind, the word “fact” just doesn’t belong in the same sentence with the phrase “magic bullet,” certainly not when we are talking about something as complicated as national healthcare.

Nevertheless, Hacker, who is an intelligent, highly-respected healthcare reformer , is dead serious. Just spread the money around, he says, and everyone will be happy—particularly the lobbyists who might otherwise object to any attempts to cut spending and eliminate some of the waste in our bloated system.

 “Buy off the opposition,” Hacker advises.  “Britain's health minister was once asked how he had gotten doctors on board for the National Health Service. His reply:  ‘I stuffed their mouths with gold.’ Money may not change everything, but it does make it easier to win friends, or at least divide and placate them. . . .”
The problem with the Clinton healthcare plan Hacker explains is that “it didn't include enough handouts to appease interest groups.” 

Still, I cannot help but wonder: Does “stuffing their mouths with gold” mean “stuffing health care legislation with pork”?  Is that really the most prudent way to design an affordable, sustainable, and effective health care system?   

But according to Hacker, Americans don’t want to hear about affordable; nor are they interested in eliminating waste.  “Most don't believe our nation spends too much on health care; they believe they spend too much.” In other words Americans are distressed that their own bills are so high.  The fact that Medicare spending is sky-rocketing, and that eventually we all will have to pay the piper, is, apparently, beyond the grasp of the average citizen.  The notion that unnecessary, often unproven and usually over-priced drugs, devices, tests and operations can be hazardous to our health is just too hard to understand.

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Imagine appointments with your primary care doctor that last 30 minutes—or longer. What if you could e-mail her when you need a prescription refill? If you have a two-minute question, she encourages you to call; she or a nurse practitioner will come to the phone. If they’re busy, they’ll return your call within a few hours.

A recent story in the Seattle Post-Intelligencer offers hope for primary care by focusing on an innovative program at Group Health Cooperative, a nonprofit health care system headquartered in the state of Washington. Under the new program, patients see their doctors less often, but when they do, it is a meaningful encounter.  And in between appointments, doctors are paid to communicate with patients in other ways.

A multi-specialty integrated health care system, Group Health, like Kaiser Permanente, provides both healthcare and insurance. Group Health’s doctors work on salary, so there are no financial incentives to “do more.” And because Group Health is both the insurer and the caregiver, the payer and the health care provider are not adversaries: they are on the same team. 

By creating its own small revolution in primary care, GroupHealth is demonstrating that private sector insurers can be part of the solution to our healthcare crisis.  In this case, the key is paying doctors for the time they spend e-mailing patients, returning phone calls, and doing research on their behalf. Because doctors are on salary, they are paid for everything they do—not just for the number of patients they manage to “see” in a given day.

In a two-year experiment, Group Health is encouraging doctors to spend more time in face-to face appointments with patients.  Given the finite number of hours on a physicians’ calendar, this means seeing patients less frequently. But doctors also keep in touch with patients by phone and e-mail.

As a result, a doctor like Dr. Patricia Boika can spend a half hour, or more, with the patient she sees.  Before she became part of this program, “The practice had become a dismal treadmill, with too many patients and not enough time, double-bookings and harried visits, and paperwork lugged home every night,” Boika, who has been a family doctor for 28 years, told the Post-Intelligencer.

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This is from the Wall Street Journal’s Washington Wire:

“Ezekiel J. Emanuel, a prominent bioethicist at the National Institutes of Health–and the brother of incoming White House Chief of Staff Rahm Emanuel–will serve as a senior counselor at the White House Office of Management and Budget on health policy, two Democratic officials said Thursday. 

“Zeke Emanuel will work closely with Department of Health and Human Services secretary-nominee Tom Daschle to formulate a national health insurance program and to try to curb the swelling cost of health insurance without adversely impacting health care.

“Two Emanuels in the White House might sound like a voluble combination, given Rahm Emanuel’s penchant for yelling, but his brother is known for being suave and soft-spoken”

As regular readers may remember, I’ve written about the plan for universal coverage that Zeke Emanuel outlines in his book Healthcare,Guaranteed in two posts: The first post begins:

“Imagine a proposal for health care reform that guarantees free, high quality health care for all Americans.

"No premiums. No deductibles. Under this plan, the government insists that all insurers offer the same comprehensive benefits to everyone including: office and home visits, hospitalization, preventive screening tests, prescription drugs, some dental care, inpatient and outpatient mental health care and physical and occupational therapy.

“These benefits are more generous than Medicare’s and more comprehensive than what 85 percent of all employers offer their employees. (Individuals who want to purchase coverage for additional services like concierge medicine, experimental drugs for serious conditions, complementary medicines or more mental health benefits could do so.)

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When President-elect Obama outlined his economic stimulus package earlier this month, he emphasized the need to invest in the healthcare system’s infrastructure by pushing for electronic health records (EHR), nationwide:   “We will make sure that every doctor’s office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year.”

On the face of it, I like the proposal because Obama is talking about spending money on something concrete, something that we definitely need, and something that, over time, should make U.S. healthcare safer and more effective.  At the end of the day, we’ll have something to point to that is just as substantial as a safe bridge and that, over the long term, should add to the health and the wealth of the nation.  If done right, the pay-off would be better, more efficient care for years to come. And here’s the bonus: a roll-out of healthcare IT would provide jobs for all of the people needed to design the technology and train healthcare providers.  

Still, this is an ambitious undertaking. And there are questions to be asked. So I began asking them. Some of the answers were eye-opening.

Why Don’t We Already Have HealthCare IT?

After all, we spend hand-over-fist in most areas of healthcare: why not here?

The problem is that the physicians and hospitals who the government expected to invest in electronic health records are least likely to benefit financially.  For example, if electronic medical records reduce the number of redundant tests, the insurer and/or the patient enjoy the financial benefit: the physician does not. In fact, if the physician does the tests in his own office, he loses money every time he doesn’t need to repeat a test.  Over time,  health care providers might realize savings from EHRs, but experience suggests that it would take at least ten years.

Since insurers would be the first to enjoy savings from more efficient care, it would make sense for them to provide the initial funding for Health IT. But so far, relatively few for-profit insurers have stepped up to the plate. 

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Randy Schubring of the Mayo Clinic’s Health Policy Center will be hosting a health care  discussion Friday, Dec. 26, at 7 in Minneapolis. Here is his invitation:

President-elect Obama has made it clear that health care reform is one of his top priorities. That's why the Obama-Biden Transition is asking people to give their own thoughts and ideas for how to fix the system at Health Care Community Discussions all across the country.  I just signed up to host a Community Discussion, and I thought you might want to come. Here are the details:

Date and time: Friday, Dec. 26, 7 p.m.

Location: 2530 East 34th Street #108
Minneapolis, MN

Hope you can make it!

Randy Schubring | Mayo Clinic Health Policy Center |  507-293-0966 | schubring.randy@mayo.edu
Mayo Clinic | 200 First Street SW | Rochester, MN 55905 | http://www.mayoclinic.org/healthpolicycenter/

Scroll down to  “HealthBeat Readers, Let’s Get Involved” to find out how you can host a health care discussion in your city.

The Dallas Morning News has done a wonderful series on end-of-life care. Thanks to 
Annie for pointing it out.

Here are excerpts from part one, written by Lee Hancock, describing an encounter at a Baylor University Medical School ICU unit between Ms. Patel, a palliative care team nurse, and Dr. Edward Taylor, a 36-year-old trauma surgeon.

Like a palliative care doctor, Patel had been specially trained to help patients who may be dying—and their families—confront excruciating questions about how much care they want.   These specialists also are trained to manage pain, a fine art that too many U.S. hospitals do not practice. Finally, palliative care specialists help other doctors and nurses face the fact that they may be losing a patient.
In this case, Hancock explains: “The middle-aged accident victim had been stranded there for weeks, in a high-tech limbo.”

" ‘He looks a mess,’" Ms. Patel told the surgeon. ‘It doesn't seem like we're going to make him better.’

“‘I don't know if we can say that,’ Dr. Taylor said, looking down at the tiny, Indian-born nurse.

“Ms. Patel's gray scrubs would fit a fourth-grader, but her vibrance and her striking British accent drew outsized attention. She was a legend throughout the medical center, where she had worked since coming from England in 1990…

“Dr. Taylor, 36, called in Ms. Patel that Thursday morning because his patient was the sickest in the unit. But the man's relatives didn't seem to get it. In the twilight zone of the ICU, it was hard for bewildered families to grasp that using more drugs and devices wasn't always the best way to show love.

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                           This Thursday, December 18 in New York

Let’s take blogging and reading blogs to another level: let’s try to translate it into communicating with our government.

 President-Elect Obama and Senator Tom Daschle, the new administration’s point-man on health care reform, say that they want healthcare reform that comes “from the ground up.” This is why they are asking Americans to “give us your ideas and input” during this holiday season.

Here is the invitation from the Office of the President-Elect  “Sign up to lead a Health Care Community Discussion in your home, community center, or even a local coffee shop, anytime from December 15th to 31st. (http://change.gov/page/s/hcdiscussion) Senator Tom Daschle, the leader of the Transition's Health Policy Team, will choose some discussions to attend in person.”  

 I’m hoping that HealthBeat readers of all political persuasions in cities around the country will decide to step up to the challenge. If you’re interested in hosting a discussion, sign up at (http://change.gov/page/s/hcdiscussion     and e-mail me at Mahar@tcf.org.  I’ll post your invitation here on HealthBeat so that people in your area can attend. (When you sign up at change.gov, you might want to let them know you’re a HealthBeat reader, and part of the HealthBeat Network.)

NYC HealthBeat reader Dr. Brad Flansbaum at Lenox Hill Hospital in Manhattan already has decided to host a conference at Lenox Hill this Thursday, December 18, from 6:30 to 8:30 p.m.

I’ll  be there, and Brad and I will put our heads together to create a few bullet points for the discussion. But we’re counting on you to drive the conversation. 

The incoming administration has signaled that it is very interested in hearing from informed constituents. Our opinion WILL make a difference.

 Here’s Brad’s invitation to everyone in the NYC area:

Hi All,

President-elect Obama has made it clear that health care reform is one of his top priorities. That's why the Obama-Biden Transition is asking people to give their own thoughts and ideas for how to fix the system at Health Care Community Discussions all across the country.

We have arranged to host a Community Discussion, and we want your voice heard.  Here are the details:

Date and time: Thursday, 12/18 at 6:30 to 8:30.
Location: 130 Black Hall, ER entrance, SW corner of Lexington and E. 77^th Street, and follow signs to Weisner Conference Center.

[BEF1] 
Hope you can make it.”

*****************************************************************

Please let me know if you’re interested in attending the NYC event by e-mailing me at mahar@tcf.org. (We’re just trying to get an idea of how many people will be coming.)

If  you’re in another city and want to host a discussion, send your invitation to the same address—mahar@tcf.org so that I can post it on HealthBeat.  Just remember, you have to host the discussion sometime between December 15  and December 31.

Recently, a somewhat starry-eyed op-ed in the New York Times suggested that a $100 billion annual investment in universal healthcare is just the medicine that our economy needs. The goal, declared Jonathan Gruber, a professor of economics at the Massachusetts Institute of Technology: “covering every American.”

It is an appealing proposition. But let me suggest that we cannot blindly invest billions in an already bloated healthcare system. We need to think through where we want the reform dollars to go.  Which sectors of a $2.3 trillion health care economy should we stimulate to insure that patients receive the safest, most effective care at a price that they can afford?

For example, should we try to create more jobs for those making diagnostic scanning equipment?

Probably not.  As Health Beat recently reported, we’re already experiencing what some call an “epidemic of diagnostic imaging.” In too many cases, patients don’t benefit.  Across the board, 20 to 50 percent of high-tech diagnostic imaging fails to provide information that improves patient diagnosis and treatment.  In some cases, false positives lead to unneeded biopsies and surgeries that harm patients.  Recent research suggests that an explosion of MRI scans for breast cancer is leading to unnecessary mastectomies. In other words, women lose a breast for no good reason.

So while GE might like more business making diagnostic imaging equipment, all of the medical research suggests that we already have more MRI units than we need, and that they are being overused. (Keep in mind, the goal of health care is not to create jobs: it is to improve the nation’s health.)

But if we simply open the door and tell insurers we’ll provide subsidies for health care for all, we can be sure that a nice chunk of the $100 billion that we invest annually will buy more testing equipment and more tests. Insurers will continue to pay for unnecessary testing because it is popular among many patients (who believe, falsely, that it provides benefits without risks) and some physicians (diagnostic imaging can be very lucrative.)  If insurers say “no” to a popular procedure, they risk losing market share.  If they say “yes” they can pass the cost along in the form of higher premiums, and taxpayers, in turn, will have to find the money to fund higher subsidies.

The problem is this: too many proposals for health care reform focus solely on universal access and run the risk of sending good money after bad. The question we need to ask is: “access to what”?

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Maggie Mahar and Niko Karvounis

Last week the New York Times published a story about one of the biggest medical trials ever organized by the federal government,  a study that showed that the newest, most expensive drugs used to treat high blood pressure (a.k.a. hypertension) work no better than inexpensive diuretics—water pills that flush excess fluid and salt from the body. Moreover, the research revealed that the pricier drugs increase the risk of heart failure and stroke. 

The trial was completed in 2002. Why is the story running now? Because six years later, the findings still have had little impact on what doctors prescribe for patients suffering from hypertension.

Allhat –which stands for the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial—demonstrated that when, it comes to preventing heart attacks, the diuretics—which have been used since the 1950s and cost only pennies a day—is just as effective as newer calcium channel blockers and ACE inhibitors that cost up to 20 times as  much.

And the diuretic is safer. Patients receiving Pfizer’s calcium channel blocker (Norvasc) had a 38 percent greater chance of heart failure than those on the diuretic. And those receiving AstraZeneca’s ACE inhibitor were exposed to a 15 percent higher risk of strokes and a 19 percent higher risk of heart failure.
Meanwhile, NYT reporter Andrew Pollack noted, the diuretics cost only about $25 a year, compared with $250 for an ACE inhibitor and $500 for a calcium channel blocker.

In a rational world, the results “should have more than doubled” use of the less expensive drugs, says Dr. Curt D. Furberg, a public health sciences professor at Wake Forest University and the former head of the Allhat steering committee.

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Whatever happened to the characters in the PBS documentary, “Fat: What No One Is Telling You,” that I wrote about here and here?

By the end of the film, the 300-pound 18-year-old who I described in part 1 had his bariatric surgery and, to his delight, lost 147 pounds. “I’m a whole human less in weight,” he exulted.   Indeed, he had lost the equivalent of his skinny twin’s total weight. (It’s worth noting that this surgery is recommended only as a last resort. And even then, a patient should make sure that his physician is an experienced bariatric surgeon who has performed many operations. The risks are real—and harrowing. Nevertheless, for this young man, the procedure was a huge success.)

What about the former tomboy who gained 125 pounds after becoming an executive at Microsoft? Humiliated when she spilled out of her airplane seat—and onto her fellow passengers—and frustrated that she could no longer participate in the sports she loved, she became even more depressed when she had difficulty getting pregnant.  

That’s when she and her over-sized husband signed up for a comprehensive program that includes doctors, nutritionists, and trainers.

They also purchased health cook books, determined to learn how to cook foods that had been foreign to their diet—such as chicken.

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