Health Wonk Review is up here. This compendium of some of the best health care posts of the past two weeks is well worth reading. 

This week, Bob Laszewski of Health Care Policy and Marketplace Review  is our host, and he is highlighting pieces that examine some of the candidates’ health care plans (Joe Padua on John McCain, Jason Shafrin on all of the Democrats, and Anthony Wright comparing candidates on both sides of the aisle) as well as California’s effort at health reform (Brian Klepper is skeptical). He also calls attention to Roy Poses’ expose of yet another greedy CFO on Health Care Renewal.  But I’m not going to try to list everything here. Check out Health Care Policy and Marketplace Review yourself—I suspect you’ll wind up putting it on your “favorites” list.

Earlier this week the Happy Hospitalist, an internist who works full-time in a hospital,  published a behind-the scenes look at the “turf wars” that doctors fight when it comes to performing certain very lucrative procedures.  Colonoscopies, for example, pay nicely, and doctors vie to do them. Bone marrow biopsies, on the other hand, belong to the group of procedures he labels the “red headed step children” of hospital care:  they’re relatively time-consuming and just don’t pay very well. As a result, the (usually) Happy Hospitalist explains, he often has a very tough time finding a specialist willing to perform one of these procedures for a patient.

Let me preface his story by pointing out that Medicare’s fee-for-service payment schedule—which has become the basis for most private insurers’ payments as well—is set and updated by a proprietary, and rather secretive advisory committee, the RVS Update Committee (or RUC).

I’ll tell you more about the RUC in the post below (“Who Decides How Much To Pay Specialists?”)  But first, read the Happy Hospitalist’s story. (Note, throughout the piece, I have inserted definitions of medical terms, in brackets.)

From: The Happy Hospitalist
TUESDAY, JANUARY 8, 2008 
“Red Headed Step Children”

“In the world of procedures, all procedures are not created equal. And when that happens, the turf wars begin. I can assure you, in just about every hospital in this country, behind the scenes politics go hand in hand about who has the right the perform what. The battles usually ensue in those procedures that are economically worth while to the doctor or group of doctors

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If you’ve read the post above about specialists vying to do lucrative procedures like colonoscopies– while avoiding equally time-consuming procedures that just don’t pay as well–you might have wondered: who sets and updates the fees for each procedure?

The answer: a Medicare advisory committee called the RVS Update Committee (or RUC).  The RUC flies under the radar. It’s quite secretive and many people have never heard of it. Yet it is enormously powerful. It sets the prices for Medicare’s fee-for-service payment schedule, a price-list that has become the basis for most private insurers’ payments as well.

Who is on the RUC? It’s dominated by specialists. So, it should come as no surprise that a specialist’s time is deemed to be worth far more than an internist’s or a family doctor’s time.  An article in the June 2007 Annals of Internal Medicine provides a quick example.

In 2005, the Medicare fee for a typical 25- to 30-minute office visit to a primary care physician in Chicago was $89.64 for a patient with a complex medical condition (Current Procedural Terminology [CPT] code 99214). By contrast, Medicare’s fee for a gastroenterologist in the outpatient department of a Chicago hospital performing a colonoscopy (CPT code 45378)–which also takes about 30 minutes—was $226.63.  And if the specialist performed the procedure in his own office, where he pays for equipment and nursing time, he could charge Medicare $422.90 for his thirty minutes.  (Of course the primary care physician also has to pay for staff and equipment, though the equipment may not be as expensive.) 

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On Gooznews last week, Merrill Goozner made a provocative argument:

“…the latest polls show the economy has eclipsed health care as the most important domestic issue among voters. Even the health care-oriented Kaiser Family Foundation’s latest poll shows the number of Americans who name health care as their primary concern fell to 30 percent in early December from 38 percent just two months earlier. When offered a list of possible issues the candidates ought to address, the economy had pulled even with health care.

“The escalating fear that the nation may be heading into a recession because of the sub-prime mortgage meltdown and sky-high gas prices has certainly played a role in the turnabout. In that sense, 2008 is beginning to look a lot like 1992. The year before that election, health care dominated the national discussion after Harrison Wofford used the issue to win a surprise victory in a special Senate election in Pennsylvania. But by the time Arkansas Gov. Bill Clinton stormed to victory in the primaries, ‘it’s the economy, stupid’ had become the Democratic standard bearer’s watchword.”

Merrill may be right: certainly health care didn’t seem to be the driving issue in Iowa, and I doubt it will determine the results in New Hampshire. (See my last post on Iowa and New Hampshire.)

And I agree that, by November, the economy may well be the paramount issue. We are heading into a recession.

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When it comes to health care, the citizens of Iowa and New Hampshire are different from you and me: they enjoy higher quality yet much more affordable health care than citizens in virtually any other state. This may help explain why health care just hasn’t seemed to be a pivotal issue in these early primaries.

The chart below (click the image for a bigger version in a new window), published in Health Affairs in 2004, rates the quality of  health care state by state (see vertical axis) while also revealing how much Medicare spends, on average, per beneficiary in each of the states each year. (See horizontal axis.) Spending has been adjusted to take into account inflation, differences in prices in different states, and differences in the age, sex and race of the Medicare population in each state.  States that spend most appear on the far right of the chart. States that provide the highest quality health care are clustered at the top.

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Yesterday I appeared on a four-person health care panel that was televised in New Hampshire.  The panel included a conservative who surprised me by arguing that the difference between the progressive candidates’ proposals for health care reform and the conservatives’ position on health care just isn’t that great.

Looking at the candidates’ proposals, I disagreed.  Put simply, the conservatives would like to make government smaller. They want to “outsource” many of government’s jobs to the private sector. They tried to privatize Social Security, and they have partially succeeded in privatizing Medicare by paying private insurers a steep premium to take care of seniors under Medicare Advantage. (See my post about the high cost of the program here).

Finally, the vote on SCHIP split along conservative/ progressive lines, with conservatives voting against expanding SCHIP. As President Bush explained, more funding for SCHIP would expand the government’s role in our health care system.

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I promised to return with more information about who halted the use of life-saving checklists in Intensive Care Units in Michigan and at Johns Hopkins. (For my earlier posts on this shocking story, click here and here).

The Office of Human Research Protections (OHRP) is the agency that has nixed the use of checklists. Who runs the OHRP?  Until his recent resignation (as of Sept. 30), Bernard Schwetz was the director of OHRP. Who is Schwetz? He is a veterinarian (DVM). That’s right, he’s vet, not a M.D.

What’s even more surprising is that from January 20, 2001 to February 2002, Schwetz, who is also a toxicologist (Ph.D.), was Acting Deputy Commissioner of the FDA. This was not a bright period in the FDA’s history. During Schwetz’s tenure, the FDA’s counsel, Dan Troy, was running the agency from behind the scenes. Troy, a Bush appointee, was well-known as a long-time foe of FDA regulation. In the 1990s, he represented Brown & Williamson Tobacco Corp. in its effort to fend off the FDA, and just months before joining the agency, he had defended Pfizer in another battle with regulation. As a U.S. News & World Report headline summed up his career change: “Mr. Outside Moves Inside: Daniel Troy Fought the FDA for Years; Now He’s Helping to Run it.” (I have documented Troy’s power in my book, Money-Driven Medicine).

As for Schwetz, what can one say about a vet/toxicologist who becomes temporary deputy commissioner of the FDA? “Political appointee” is the phrase that comes to mind.

I’m told that the OHRP is a “strange creature.” It was created in 2000 to replace the small, underfunded Office of Protection from Research Risks. That office reported to the NIH. OHRP, by contrast, reports directly to the Assistant Secretary of Health, putting it under the White House’s control.

OHRP began sending what only can be described as threatening letters to Michigan and Johns Hopkins last summer—on Schwetz’s watch. He announced his resignation at the beginning of August. I haven’t been able to find an explanation for the resignation or whether it is in any way connected to OHRP’s decision about the checklist.

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Perhaps you saw the headlines over the holidays:

• “CIGNA Defends Decision To Let Teen Die—On Christmas Eve”
• “As CIGNA Insurance Waffles on Liver Transplant, Girl Dies”
• “Lawyer: CIGNA’s refusal to pay for liver transplant ‘killed’ teen”
• “Teenage Girl Dies So CIGNA Execs Can Get Richer”
• Metroblog: "Merry ******* Christmas, From  CIGNA Healthcare "

Without question, this is a tragic story. Here are the bald facts: Nataline Sarkisyan, a 17-year-old who had been battling leukemia for three years, received a bone marrow transplant from her brother the day before Thanksgiving. She then suffered complications; her liver failed, and she went into a coma. At that point her doctors at the UCLA Medical Center recommended a liver transplant, saying that the transplant would give her a 65 percent chance of living another six months.  Within four days, a matching donor was found.

But on December 11th her insurer, CIGNA, refused to cover the transplant on the grounds that for a patient this sick, the transplant would be an “experimental procedure.” And her insurance policy "does not cover experimental, investigational and unproven services.” 

The doctors told the family that their only alternative would be to make a $75,000 down payment on the operation. Unfortunately, the family didn’t have $75,000. 

Observers both in the mainstream media and in the blogosphere were outraged when they heard that CIGNA had denied coverage.  Daily Kos led the protest with “Murder By Spreadsheet: CIGNA  Denies Claim and 17-Year-Old Will Die.” Responding to the firestorm, on December 20 CIGNA relented, saying that  "despite a lack of medical evidence regarding the effectiveness of such treatment,” it would cover the transplant.

The letter from CIGNA came too late. That same day, the hospital called to say that Nataline’s condition was deteriorating and her family was forced to make the decision to take her off life support.  She died within the hour.  The next day the Sarkisyan’s lawyer announced that the family planned to sue CIGNA for “malicious” murder.

This is both a tragic tale and a complicated story—far more complicated than the headlines suggest.  As Dr. John Ford, an assistant professor at UCLA’s medical school observed on his blog, California Medicine Man, “While I’m not surprised at the intensity of emotion that has arisen from this case, the utterly inflammatory and often mindless rhetoric being propagated is sobering. It seems that nuance has taken a hike, never to reveal itself.” 

Here are just a few of the questions that this vexed and vexing case raises:

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Today (Sunday, Dec. 30) the New York Times published a shocking op-ed by Dr. Atul Gawande revealing that a U.S. government agency has stopped an enormously successful "checklist" program that was being used to reduce infections in intensive care units at Johns Hopkins and throughout the state of Michigan. (To see my original piece  on checklists, scroll down to my Dec. 14 post below.)

Below, an excerpt from today’s op-ed:

" In Bethesda, Md., in a squat building off a suburban parkway, sits a small federal agency called the Office for Human Research Protections. Its aim is to protect people. But lately you have to wonder. Consider this recent case.

"A year ago, researchers at Johns Hopkins University published the results of a program that instituted in nearly every intensive care unit in Michigan a simple five-step checklist designed to prevent certain hospital infections. . .

"The results were stunning. . . . Over 18 months, the program saved more than 1,500 lives and nearly $200 million

"Yet this past month, the Office for Human Research Protections shut the program down. . .

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I hope everyone has a wonderful holiday.  Health Beat will be taking a vacation—but we’ll be back January 2. And sometime early in the New Year, we’ll have a new design—with the larger typeface that some of you have asked for.  Be well.