My idea of a vacation is, of course, to blog.
TPM Cafe asked TPM contributors to write
about the convention and the future
of the Democratic Party.
You can find the post here http://tpmcafe.talkingpointsmemo.com/2008/08/28/the_future_of_the_democratic_p_1/
Yesterday, the Census Bureau came out with a report that provides
a compelling window on poverty and health in America.
It’s somewhat modestly titled “Income, Poverty and Health
Insurance Coverage in the United States, 2007.” I would suggest it deserves a headline that
does justice to its sweep, perhaps “Connecting the Dots: Health and Poverty, America’s
Shifting Priorities, 1960-2007.
Begin with this chart:
At first glance, what is most striking is how well President
Lyndon B. Johnson’s “War on Poverty” worked in the late 1960s. Seniors–who were then the poorest group in
the U.S– benefited most. The share of Americans over 65 scraping along
somewhere below the poverty line plummeted from roughly 30 percent in 1965 to
just over 15 percent in the early 1970s. Johnson made Medicare and Medicaid
legislation a priority, and when it passed Congress in 1965, it made an
enormous difference.
The War on Poverty also helped kids: the share of the
nation’s children trapped in poor households fell from roughly 23 percent in
1965 to 15 percent during the Carter years.
By contrast, look at what has happened during the latest
economic cycle. As the Economic Policy
Institute’s Jared Bernstein points out, “Despite
strong overall economic growth, the
cycle that began in 2000 and ended late last year has turned out to be “one of
the weakest on record for working families.”
Recently BuckEye Surgeon offered a compelling window on what it is like to be a surgeon (or, for that matter, any type of physician), and realize that patients think that you are practicing pure science.
First, he admitted that he had been reading Cicero, (yes, that Cicero—the late, great Roman orator and statesman), and had come across a quotation that “grabbed him”:
"For the better he is at his job, the more frightened he feels about the difficulty… about its uncertain fate… about what the audience expects of him."
“Cicero was talking about the stresses that afflict a great orator; the pressure to reproduce the excellence of past speeches,” Buckeye explains. “The audience has come to listen and expectations are high and even one minor insignificant error can ruin the overall impression of an otherwise articulate, inspiring speech.
“In many ways, this is what we’ve come to in medicine. The expectations are almost insurmountable. Infallibility is the performance standard. The delivery of healthcare has been relegated to the category of ‘commodity, like automobiles and hair care products and soybeans. Where’s my warranty, my guarantee? Why did I get an infection? Why didn’t you realize I had breast cancer when it was 0.5mm instead of 2mm? Did you wash your hands well enough before you came into my room?
I first wrote about Gardasil on The American Prospect online in the summer of 2006, just weeks before the Merck vaccine designed to protect against cervical cancer went to market.
There, I noted that “the hullabaloo began in June when the FDA approved Gardasil, a vaccine widely described as ‘100 percent effective’ in preventing cervical cancer, a disease that kills some 233,000 women worldwide each year. The drumbeat grew louder last month when a federal panel recommended that all American girls and women ages 11 to 26 should be inoculated. And now there is talk that states may mandate the vaccine for all school-age children.
“But before prescribing for the entire population,” I suggested, “it’s worth asking a few questions: Why does the vaccine cost $360 for a three-shot regimen? How much do we know about the new product? And is this a cost-effective use of health-care dollars?”
I reported what we knew at the time: Although Gardasil was commonly described as “100 percent effective” if you scrolled down far enough in most news stories, you would find that the vaccine is “100 percent effective” against “only two strains of HPV (human papillomavirus) that causes cervical cancer. And those two account for just 70 percent of all cases. The vaccine has no effect on the viral strains which account for the other 30 percent.”
Read a little further and you would discover that because the vaccine protects against less than three-quarters of all cases, inoculated patients still will need regular Pap smear tests to check for signs of the disease.
What this country needs is more lobbyists, representing more interests groups. This is what Nicholas Lemann, Dean of the Columbia School of Journalism, all but declares in a contrarian piece published in a recent New Yorker. Basing his argument on The Process of Government: A Study of Social Pressure, a classic written by Arthur Fisher Bentley in 1908, Lemann declares that in the end, politics is all “about interest groups struggling against other groups and finally making deals, through politicians and agencies and courts.” And this, he implies, is the way it should be.
Under Bentley’s rules there is no such thing as “the public,” Lemann explains. “There are only groups.” And “the public interest” is a “useless concept,” because there is “nothing which is best literally for the whole people.” Bentley dismisses any idea of what I might call “the public good.” We live in a society divided against itself, in groups with very discreet, often warring interests. So much for making common cause for the common good.
As I read Lemann’s piece, I could not help but wonder: what does this mean for national healthcare reform? And I realized that there are some reformers who endorse something uncomfortably close to the process that Lemann describes.
Like Lemann, they believe that reform can be accomplished only by letting the interest groups duke it out. Big Pharma, the device-makers, hospitals and insurers all should take their rightful places at the negotiating table (after all, they paid our legislators for those seats), alongside primary care docs and RNs, surgeons and radiologists, hospital workers and hospital administrators, each group defending its turf. Then there’s the AARP, the AMA and the AHA, the libertarians who oppose mandates, the progressives who want mandates…But wait, didn’t I leave someone out?
Oh, right, the patients. When elephants fight, says a Swahili proverb, the grass suffers.
When Medicare first created a fee schedule, critics suggested that it was a Marxist invention. Nevertheless, the schedule, which lists what Medicare is willing to pay for some 7,000 procedures, has become the master list for physician reimbursement in our health care system: most private insurers peg their payments to the Medicare schedule.
The notion of deciding the precise worth of some 7,000 diagnostic and therapeutic procedures is mind-boggling. How exactly does Medicare do it?
The process began in the late 1980s when officials at the Department of Health and Human Services decided that the way Medicare paid doctors should be overhauled. At the time, Medicare was reimbursing physicians based on what was considered “customary, prevailing and reasonable” in a particular market —in other words the “market value” of the service in that region.
Instead, reformers urged Congress to begin paying doctors in a way that reflected the real cost, to the doctor, of providing the service. (This is where Marx comes in: rather than letting the local market decide what a service is worth “the system appears to be based on the Marxist ‘labor theory of value,’” sputtered Susan Mandel in a 1990 piece in the National Review.)
But to many in Congress, the notion that physicians should be reimbursed for what it costs them to do what they do—plus a reasonable profit—seemed on the face of it, a sound proposal. The problem, of course, lies in determining what the true “cost” to the physician is.
Did you ever wonder why hospitals run those radio ads? In the U.S., hospitals are always trawling for well-heeled, well-insured patients—and the doctors who bring those patients through the door. And now, the Columbia Journalism Review reveals, some TV stations and newspapers have taken the hype one step further, by forming “Unhealthy Alliances” with individual hospitals.
But first consider the larger picture.
In the U.S. hospital advertising began in the 1970s, when the money really began streaming into the health care industry. Meanwhile, other countries did not allow medical centers to peddle their services to the public.
Indeed, in the U.K. the National Health Service decreed that hospitals could promote themselves “direct-to-consumers” just a few months ago, bringing an end to what had been a fairly acrimonious debate. Dr Laurence Buckman, a leading member of the British Medical Association’s (BMA’s) General Practitioners’ committee, was an early critic of the idea: "Patients want money to be spent on their healthcare, not spent on advertising to doctors so the hospital makes more money. The health service is not about making money, it is about delivering care for patients."
Dr Jonathan Fielden, chairman of the BMA’s consultants’ committee, told the BBC: "It is a sad indictment of government policy to consider spending public money on advertising NHS services when hospitals are having to make cutbacks in patient care…in order to save money."
Commenting on “Surgeons and Other Physicians: A Cultural Divide,” a reader who recently found himself in an OR with his wife offers his perspective. This is not meant as a rebuttal to Dr. Cohn’s post. I think that the two perspectives are both equally true—and that OR cultures may vary widely, from one hospital to another. I would also like to hear some surgical nurses weigh in.
“jd” writes:
“The domination exhibited by physicians, particularly surgeons, is about far more than verbal abuse and yelling. I don’t doubt those defending their experience who say that they haven’t seen many angry tantrums by surgeons. But I think we’re getting distracted by the most extreme displays so that we miss the very real and dangerous power dynamics here.
“I happen to have just been in the OR a couple of weeks ago with my wife, who was undergoing an emergency C-section. It was performed by obstetricians, as most are. There was one attending and one (I’m guessing) resident who was being trained during the operation. Their tone of voice and demeanor was perfectly pleasant throughout.
Dr. Kenneth Cohn, a surgeon and blogger, offered a particularly thoughtful response to my post “Surgeons and Other Physicians: The Cultural Divide.” First, let me introduce him.
On his blog, Cohn describes himself as a “board-certified general surgeon currently splitting time between providing locum tenens surgical coverage in New Hampshire and Vermont and working as a consultant at Cambridge Management Group, which specializes in physician-physician and physician-administrator communication issues. I am a recovering academic surgeon who is passionate about helping physicians, nurses, hospital leaders, and board members work together.”
Let me add that I’m impressed by his blog, Collaborative Confession, and that we’re adding it to our blogroll.
In his comment here on Health Beat, Cohn explained that his training was very different from the surgical training I described in the post: