This week the Disease Management Care Blog hosted Health Wonk Review, and did it with style. (http://diseasemanagementcareblog.blogspot.com/2008/09/welcome-to-health-wonk-review-political.html)

Spotlighting some of the best health blogs of the past two weeks, Jaan Sidorov noted that Joe Paduda, editor of Managed Care Matters, took on the “Free marketeers who have been lauding Gov. Sarah Palin’s efforts to eliminate Alaska’s restrictions on new health care technology and facilities.”  Paduda reminds his readers that we have “a long line of well-documented, rigorously-researched studies that clearly and unequivocally prove supply drives health care costs. The more health care facilities, beds, technology, the more physicians and care givers there are, the higher the cost and the worse the outcomes.”  In other words, there is good reason to restrict how much medical technology we purchase. If we buy more than a community truly needs, we’ll wind up with more overtreatment—and patients will suffer.

Meanwhile, Sidorov reports, over at The Health Care Blog, Matthew Holt has a little fun with America’s Health Insurance Plan’s President and CEO Karen Ignagni.  Its seems that Ignagni occasionally forgets that she earns her $1.3 million salary by heading up a trade group that represents for-profit insurers, and begins talking about how the insurance industry needs to make a profit because it wants to fulfill its “mission.”  As Matthew points out, “No Margin, No Mission” is the motto of non-profit hospitals –institutions that actually do have a social “mission” to serve their communities.

Neil Versel of the Healthcare IT Blog shares the good news and the bad news. The good: Rep. Pete Stark (D-CA) has introduced legislation with some commonsense reforms, including an open source EHR, the promotion of de-identified data use, and clarification of HIPAA. The bad: the likelihood that Stark’s legislation will pass? “Zero.”

Finally The New America Foundation’s  New health Dialogue blog asked Leif Wellington Haase, director of New America’s California Program, and Micah Weinberg, a research fellow in the California program, to update readers on where health reform stands in California. Their entire post is well worth reading, but here’s the punch-line: “Governor Schwarzenegger’s will to pass health reform remains strong, but his approval ratings have tumbled and he even faces the possibility of a recall vote sponsored by the prison guards’ union.”  Only in California.

I’ve traveling, so I’m giving you just a light sampling of this particularly well written Health Wonk Review. Read the entire post by clicking (http://diseasemanagementcareblog.blogspot.com/2008/09/welcome-to-health-wonk-review-political.html

Princeton economist Uwe Reinhardt is well known as one of the bluntest—and wittiest—critics of U.S. Healthcare.  Last week, we both spoke at a conference organized by Princeton’s Policy Research Institute on “Access to Universal Health Care: New Jersey, the Nation and the Globe. As usual, I learned something from Professor Reinhardt.

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Earlier this year, New Jersey Governor Jon Corzine received a somewhat startling letter from Princeton economist Uwe Reinhardt. The missive was appended to a report from the “New Jersey Commission on Rationalizing Health Care Resources,” a Commission that Corzine had asked Reinhardt to chair.

In the letter, Reinhardt expresses “some personal observations on the inconsistent expectations Americans have of their health system,” describing “these inconsistencies” as “a form of cognitive dissonance.”  Reinhardt goes on to explain that, in his view, these inconsistencies reflect “certain deeply ingrained traits in American culture that stand in the way of a rational health care system.”

He concludes: “In short, Governor Corzine, in my professional view, the extraordinarily expensive, often excellent just as often dysfunctional, confused and confusing American health system is a faithful reflection of the minds and souls making up America’s body politic.”

After reading the letter, Governor Corzine had one question: “You’re not going to publish this in the report, are you?”

In fact, the letter did appear at the front of the report. And last week, at a conference on “Access to Universal Health Care: New Jersey, the Nation and the Globe” sponsored by Princeton’s Policy Research Institute, Reinhardt circulated said letter.  It served as a good companion to Reinhardt’s speech, which compared what we euphemistically call our health care “system” to systems in other parts of the world.

Reinhardt began his talk by considering the fact that, in the U.S. insurance is often tied to one’s job.
“No one –in his wildest dreams—Drunk!!—would design a health care system based on employment,” Reinhardt declared, barely containing his outrage at such a truly bone-headed idea. After all, the unintended–but inevitable– consequence of an employer-based system is this:  if you lose your job, you also lose your health insurance—at exactly the worst possible time.   

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Merrill Goozner, editor of GoozNews, broke this story first in Integrity in Science Watch, published by the Center for Science in the Public Interest, and then reported it on GoozNews.

The post deserves maximum exposure because it illustrates just how underhanded the FDA has become in recent years—while posing as a regulatory agency.

It seems that the Food and Drug Administration turned to “a non-profit run by a pharmaceutical industry advertising consultant to help design its new campaign to educate consumers about direct-to-consumer drug advertising. The FDA’s recently launched website, “Be Smart About Prescription Drug Advertising: A Guide for Consumers,” was developed by EthicAd, a non-profit run by Michael Shaw out of the offices of Atlanta-based Shaw Science Partners. Shaw’s firm claims credit for having helped launch over 25 pharmaceuticals, including Viagra, Celebrex, Zoloft, Cymbalta, and Rezulin, which was later withdrawn from the market because of safety concerns.”

Goozner points out that the site, “which claims DTC ads ‘can provide useful information to consumers,’ focuses its home page on examples of legally correct and incorrect ads—information more useful to ad designers who want to avoid running afoul of FDA regulations than to consumers. It does invite consumers to report violations of the law to the FDA’s division of Drug Marketing, Advertising and Communication.

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At “Number Needed to Treat,” Josh, a public health expert and blogger, provides a welcome addition to my recent post on med school tuition http://numberneededtotreat.wordpress.com/2008/09/09/how-about-the-cost-of-applying-to-medical-school/

I wrote about how the cost of med school narrows the pool of applicants. Josh explains that even the copy of applying is well beyond what many students (and their families) can afford.

Josh writes:

“What struck me about Mahar’s discussion of the subject was a quote at the end of her article:

“According to the NEJM, a recent national survey of under-represented students reveals that the cost of attending medical school was the number-one reason they did not apply.

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       The post below,  "Free Tuition For Medical Students?"  (Sept. 9),  began a dicussion on the
"comments" thread about why med school education is so very expensive.

       Wouldn’t it be cheaper if students did more of their learning online?  Don’t they take a great many courses that ultimatley will be of little help in their chosen specialty?

       If you’re interested in my answer, see the reply I posted today, addressed to Barry and Red Baron at the top of the "comments" thread.

Imagine being a pediatrician who treats only very, very sick children.  Many will live; and many will die. And as a physician you realize that, while you can help, you do not decide.  No matter how brilliant you are, your tools are limited.  Despite the arsenal of medical technology at your disposal, in many cases you are forced to recognize that medicine is still an infant science. Often, you must rely on intuition– barely articulate knowledge that comes with long experience.   And, even then, sometimes you won’t be able to save your patient –a child who hasn’t yet had a chance to live.

I can’t imagine a harder row to hoe—except to be the parent of a child in a Pediatric Intensive Care Unit (PICU).

In Your Critically Ill Child: Life and Death Choices Parents Must Face, Dr. Christopher Johnson, co-founder of the Mayo Clinic’s PICU  in Rochester, Minnesota manages to address both audiences: parents and physicians.

Ostensibly, the book is aimed at parents. But I would urge any doctor who treats seriously ill or injured children to read it.  Johnson, who has practiced pediatric intensive care for twenty-five years, offers a window on the parents’ world, and essential advice on how to collaborate with them.

The first tale focuses on Robert, a healthy five-year-old who suddenly and mysteriously lapses into a disoriented and ultimately hallucinatory state.  “By the time he arrived at the PICU he was agitated and combative. He could not recognize his mother. By that afternoon, he was developing all the signs of fast developing acute liver failure. “

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Always a trailblazer, The Mayo Clinic’s Medical School has had a generous scholarship program for the past 20 years that enables about 60 percent of its students to attend school tuition-free. The 50 students who started at Mayo last summer each received $25,000 to use towards tuition of $29,200. Students also are eligible to receive an additional $2,000 to $5,000 a year based on need, said David Dahlen, director of student financial aid at Mayo, based in Rochester, Minn.

Now, a few other schools are experimenting with much-needed financial relief for medical students. Most notably, the University of Central Florida’s brand new med school is offering four-year scholarships for tuition, fees and living expenses for every member of first-year class.  Students have until December to apply; already, the school has received 2,996 applications for its charter class of 40.

The Wall Street Journal reports that the $7 million needed to fund the charter class came from individuals and private philanthropies. There was no single donor who did most of the work; the two largest gifts were each a bit over $300,000. Perhaps other medical schools could follow this model.

The bad news is that this first class is the only one that will receive such a sweet deal. There will be some scholarships for students in subsequent classes, but essentially the University of Central Florida is using the financial packages to attract a top entering class, hoping that this will set the pace for the school’s future.

Mayo, of course, doesn’t need to offer financial enticements to draw the best students. It is simply part of the school’s “philosophy that your qualifications, motivation and commitment to service–rather than finances–should guide your decision to apply to medical school.” 

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Somehow, when describing the posts that Health Wonk Review highlighted as the best healthcare posts of the last two weeks, I managed to point to the wrong post on Roy Poses Health Care Renewal.

Poses is always on the news—and digging deeper. In this post he begins by giving you the background to the story: “in 1989, the U.S. Department of Justice tried but failed to prevent a merger between nonprofit Carilion Health System and the  former railroad town’s other hospital. The merger, it warned in an unsuccessful antitrust lawsuit, would create a monopoly over medical care in the area.

“After the 1989 merger, Carilion continued to operate Roanoke’s two hospitals separately,” Poses explains. “It later consolidated the hospital boards and in 2006, transferred most of Roanoke Community Hospital’s staff and services to a renovated and enlarged Roanoke Memorial Hospital.

“The moves eliminated any hospital competition in Roanoke proper….

“[Carilion CEO Dr Murphy] was convinced that the cost and quality of care in Roanoke could be improved if doctors worked in a more centralized system. In June 2006, he announced a seven-year, $100 million plan to transform Carilion into a multispecialty clinic, like the Mayo Clinic.

“Carilion began approaching private physician groups, offering to buy their practices and pay their salaries.”

Poses then goes on to look at what effect Dr. Murphy’s advocacy of more centralization had. See the full post here. 

You’ll find Health Wonk Review, a compendium of some of the best healthcare posts of the past two weeks here.

Not surprisingly, some bloggers have taken on John Goodman, president of the National Center for Policy Analysis, for suggesting that the Census Bureau’s report on the number of uninsured this country is wrong. Goodman claims that anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort.(Note: the National Center of Policy Analysis is a right-leaning think tank and Goodman helped craft Senator McCain’s health care policy.)

"So I have a solution. And it will cost not one thin dime," Mr. Goodman added: "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured.

The Health Care Blog’s Matthew Holt suggests that Goodman must be joking. “Or,”Holt asks, “is he just mean?”

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A friend who lives in Boston complained, not long ago, about not being able to find a physician. In Boston?  “Come on,” I said. “This is like claiming you couldn’t find a liquor store.”

“They’re all oncologists and cardiologists,” he grumbled. “Last week I cut my hand badly enough that it needed stitches. I have good insurance. But I couldn’t get an appointment with my family doctor—or any of my friends’ doctors. I didn’t want to spend hours in the ER. So I wound up going to my sister’s house. She sewed it up at her kitchen table.”

His experience is not as unusual as it sounds. Some 56 million Americans do not have a regular source of care according to the National Association of Community Health Centers (NACHC) — even though many of them do have insurance. The problem is a shortage of primary care physicians (PCPs) in many parts of the country, particularly, but not exclusively, in poorer communities.

Even Docs Have to Call In Favors 

Not long ago, Bob Wachter, Professor and Associate Chairman of the Department of Medicine  at the University of California, San Francisco (UCSF) , and author of Wachter’s World warned his readers: “The Long-Awaited Crisis in Primary Care: It’s Heeere.” 

Indeed, if you try get an appointment at UCSF’s general medicine practice, you will find that it is “closed” –even if you are an UCSF physician. They just aren’t taking any new patients. “Turns out we’re not alone,” Wachter adds. “Mass General also is not accepting any new primary care patients.” 

He calls attention to “to two very powerful NPR reports on the topic – the first, a WBUR special by healthcare journalist Rachel Gotbaum called ‘The Doctor Can’t See You Now,’ is the best reporting on this looming disaster I’ve heard .

Wachter summarizes highlights:  “Getting a ‘regular doctor’ (a PCP) at Mass General now takes the combination of cajoling, pleading, and knowing somebody generally referred to as ‘working the system.’ In other words, the process of finding a primary care doc is now like getting a great table in a trendy restaurant.

“The report also makes clear that providing more ‘access’ through expanded insurance coverage won’t do the trick,” Wachter explains.  “Massachusetts, you’ll recall, markedly expanded its coverage a couple of years ago (in legislation proposed by that ex-liberal, Mitt Romney). Scott Jasbon, a 47 year-old contractor/bartender, thought he was all set when he enrolled in one of Massachusetts’ subsidized health plans. He was wrong.

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