Health policy is best when it stands on the shoulders of rigorous scientific research—for example, restricting tobacco makes sense because it’s proven to reduce cancer rates and mortality. But sometimes health policy is built on a slightly shakier premise; one that balances sound science with the need to avoid controversy. The government’s policy on the pandemic swine flu vaccine is an example of this latter approach.

The decision to make the vaccine voluntary for health care workers (except in New York) is one way the government has avoided public outcry. The decision by the Center for Disease Control to not add adjuvants—substances that activate the immune system and make the vaccines more powerful—to the shots, even though doing so would have helped alleviate the delays and shortages we are currently experiencing, is another. Neither of these decisions was rooted in evidence-based concerns about public safety. And they ultimately reduce the widespread health benefits of the vaccination campaign.

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Conservatives have argued that abortion has no place in a health care bill—I couldn’t agree more (although for completely different reasons…). In fact, I think individual insurers should be the ones to decide whether or not it makes sense for them to offer the benefit to women. We are wasting far too much time and political capital on an issue that has little to do with the overall goals of reform.

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As debate over the cost of health reform intensifies, it is worth repeating that significant savings will result from making fundamental changes in the way health care is delivered. Here at Healthbeat, we have written extensively about how cutting the waste and over-treatment out of the current health care system will not only reduce the cost of care, but also lead to better outcomes for patients. But there is nothing like a real-life experience to drive this message home.

Recently, my neighbor called and asked if I would walk with her to her internist’s office just two blocks away. Mary is 80 years old and had been feeling dizzy and unsteady on her feet for over a week. Since she has hypertension, she wanted the doctor to check her blood pressure to make sure it wasn’t contributing to her symptoms.

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Drug companies spent $5.0 billion on marketing prescription drugs directly to consumers last year and, as I have written in the past,  these ads have paid off. Studies have found that every dollar spent on DTC ads generates up to four dollars in additional sales of new drugs that are often only marginally better than far cheaper, generic versions or older drugs.

But as companies cut advertising budgets and introduce drugs that command smaller markets, there are signs that the days of $100 million-plus DTC ad campaigns might be over. A recent report by TNS Media, (a company that tracks media ads) found that DTC drug advertising was down 8% last year. Another survey of pharmaceutical industry marketers found that 58% of them plan to decrease DTC advertising this year, up from 28% in 2008.

One reason for the slowdown, according to the TNS report, is that companies are introducing fewer blockbuster drugs; the newest entries are approved for narrower uses with fewer potential patients and weaker sales projections. The report doesn’t mention that consumers also appear to be fed up with incessant advertising for erectile dysfunction, sleep problems and overactive bladder, and might be tuning out many of these mass-market missives. Drug companies also are facing keener oversight from policy makers who question the educational benefit of some DTC advertising and are examining their roll in increasing health care costs.

So where do drug companies go next to market their drugs? It turns out that many companies are refocusing their marketing efforts on an old, familiar target—physicians and their prescription pads.

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Mandatory vaccination programs are seldom without controversy. Since the early 1900’s when public health workers went door-to-door inoculating people against smallpox and authorities blocked unvaccinated children from attending school, these widespread campaigns have been met with court challenges and public opposition. The underlying issue has always been that mandates threaten medical liberty—the freedom for individuals to choose which medical interventions they want and which they don’t want. But when it comes to vaccines and infectious disease, in the eyes of the law, protecting public health often trumps individual choice.

It was predictable then, that these same tensions would surface when New York State and some large hospital systems in other areas made H1N1 vaccines mandatory for health care workers. In New York, health care workers like nurses, aides, emergency room clerks, food service workers, etc. are all required to get both the seasonal and the swine flu vaccines by Nov. 30, or risk losing their jobs. The idea is that without being vaccinated, these workers pose a threat of infection to vulnerable patients, and also, in the event of a widespread outbreak, they are more likely to get sick and be unable to work when needed most.

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October is National Breast Cancer Awareness Month and the sea of pink has reached tidal-wave proportions. Every conceivable product from yogurt to running shoes to breakfast cereal now sports the ubiquitous pink ribbon. This month some NFL players will wear pink cleats, still more will don helmets festooned with pink ribbons, and legions of supporters are participating in walks, runs and bike rides to raise money for breast cancer causes. The collective spirit has been awakened; the American public wants progress on breast cancer!

But besides being a great marketing tool for selling “things,” what, ultimately, is the purpose of National Breast Cancer Awareness Month? The concept was introduced in 1985 by AstraZeneca, the giant international pharmaceutical company that makes the breast cancer drugs tamoxifen and Arimidex. The company’s aim was to promote regular mammograms as the most effective weapon in fighting breast cancer. It has since enlisted the support of such venerable groups as the American Cancer Society, the American College of Radiology, the National Cancer Institute and the Center for Disease Control, among others in this campaign.

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Earlier this year when President Obama told the graduates of Notre Dame that the country needed to find “common ground” on abortion, it’s likely he envisioned national reconciliation on an issue that has fiercely divided the country for decades. But when it comes to health care reform, Democrats are hoping to find  “common ground” through balky legislation that would extend the reach of the current ban on federal funding for abortion to include all plans that participate in health insurance exchanges.

These provisions, contained in the Senate Finance bill and also in the Capps Amendment passed by the House Energy and Commerce Committee, are designed to be “abortion neutral,” meaning that they don’t restrict or expand abortion rights beyond the status quo. The status quo is as follows: Although Roe vs. Wade ensures access to safe, legal, abortion; since 1976, the Hyde Amendment has banned federal funding for abortion except in the case of rape, incest or threat to the life of the mother. This ban currently applies to Medicaid beneficiaries and also to federal employees and military personnel.

Obama has already said that abortion will not be included in any minimum benefits package mandated by the government. The Senate Finance and House Energy committee reform plans reiterate this provision; but they do allow insurers who choose to offer abortion as a covered service to participate in the exchanges. They just can’t use any federal funds to help pay for these services.

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If nonprofit hospitals spend far less money on providing charity
care for the poor and uninsured than the value of their federal, state
and local tax exemptions, do they deserve those exemptions? What about
if they turn away indigent patients or hound them with aggressive
collection practices?

In May, the Senate Finance Committee
chairman Max Baucus, and ranking Republican Charles Grassley seemed to
agree that nonprofit hospitals have to start acting more like
nonprofits or they could risk losing their benefits. The committee
introduced a bipartisan proposal that would have required nonprofit
hospitals to provide a minimum amount of charity care, limit how much
they charge the uninsured, and to scale back aggressive collection
processes or face an excise tax or even an end to their tax-exempt
status.

But when the Senate committee released its watered-down
version of health care reform earlier this month, these stringent new
standards emerged equally weakened. Gone was the requirement that
hospitals provide a minimum of uncompensated care. Gone was the threat
of an excise tax, and gone was the threat that hospitals could lose
their tax-exempt status if they didn’t comply.

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OK, so apparently after Joe Wilson was publicly rebuked for calling the President a liar, the administration decided rather than ignore the outburst, they’d throw him—and his fellow xenophobes, a bone. Obama has made it clear from the start that undocumented immigrants will not have access to any government programs or subsidies for health care. But over the weekend, the administration decided to go further and released this statement about limiting access to the proposed health exchanges on Monday:

“Under President Obama's plan, undocumented immigrants would not be allowed to enter the exchange. People who are lawfully present in this country would be able to participate in the exchange.”

That statement, which echoes a provision that is included in the newly-released Senate Finance Committee’s version of health reform, means that even undocumented workers who want to pay out of pocket for health insurance—with no government subsidy—will be denied access to the exchanges.

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Jack Coulehan is a physician and senior fellow at the Center for Medical Humanities, Compassionate Care, and Bioethics at Stony Brook University in Stony Brook, NY. He describes himself as “not only an experienced physician, but also an advocate—in fact, a teacher—of standard-of-care practice.”

But he was no match for the vagaries of the hospital emergency room.

In the most recent issue of Health Affairs, Coulehan writes about hearing tales from friends about being “caught in a web of excessive and unnecessary medical testing” when they went to their doctors for seemingly routine problems. Although sympathetic, he couldn't really relate.

He goes on to say, “Many of the tales also included delays in receiving their test results, frequent referrals to specialists, and poor coordination among health professionals. Naturally, I’d express sympathy or outrage, whichever the speaker seemed to expect, but internally I’d pat myself on the back. I felt fortunate that there was absolutely no way I’d ever be stuck in such a scenario.”

Well, it turns out that Coulehan was wrong. A bout with self-diagnosed shingles on Easter Sunday sent him to the emergency room “to confirm the diagnosis and get my prescriptions.” Instead, Coulehan ended up spending all day in the ER, seeing an ophthalmologist and neurologist, having two MRIs and a CT scan and racking up $9,000 in medical charges.

The tale he tells of “the Great ER Caper,” provides a clear example of the  “unnecessary testing, inappropriate consultation, and uncoordinated care” that are rampant in hospital ERs and throughout the health care system. Chastened by this experience of winding up as “a poster boy for excessive medicine,” Coulehan asks;

“How can we make stories like mine less common? The only way is an approach to health care reform that encourages well-coordinated, standard-of-care practice and one that simultaneously discourages the irrational shotgun approach to medicine.”