It’s no secret that the pharmaceutical industry trades in junk science. We’ve talked about how prescription drug companies distort research many times here on Health Beat, focusing on how companies fudge measures of drug effectiveness and generally control our knowledge of what works in medication. Big Pharma’s track record of shady science is a serious problem, especially considering the fact that recent discussions about creating a Comparative-Effectiveness Research Institute currently hold a place for prescription drug companies on the organization’s board.

The obvious problem is that, to the pharmaceutical industry, “research” is just a code-word for “smart-sounding marketing.” If you really want a sense of how deep this deception runs, consider the fact that the prescription drug industry relies on so-called “research” not just to shill its drugs, but also to argue that it has a vital role to play in shaping the doctor-patient relationship for the better.

This dubious claim comes in the June 2008 issue of PharmaVoice where Meaghan Onofrey from CommonHealth, a pharma marketing consulting firm, pens a piece arguing that coaching from the prescription drug industry can make sure that “physicians and patients speak the same language” so that “everyone wins.” According to Onofrey, “one case study illustrates [how marketers can help physicians improve their communication]: by videotaping primary-care physicians, who were struggling to assess migraine prevention candidacy with their migraine patients.” According to Onofrey, it turned out that the doctors were actually asking the wrong questions of their patients. In working with key opinion leaders and advocacy groups, a simple solution was formulated to address the issue. These same physicians were taught to ask a single question to help them more simply and clearly identify the patients’ candidacy for migraine prevention.”

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Last month I wrote a post highlighting a truly boneheaded development in the Department of Defense (DoD): the introduction of AHLTA, a new system of electronic medical records for the military. Usually I’m a big fan of electronic medical records (EMRs), but not in this case  AHLTA is an entirely new system built by military contractors and funded by taxpayer dollars. Its mere existence is wasteful, because the military has long had a high-quality health care IT system in place called VistA, the Veteran Administration’s (VA) EMR system. And VistA  could have served as a very efficient foundation for modernize military health records. 

As I’ve mentioned in the past, VistA has quite a lot going for it: the VA has improved productivity by 6 percent a year since it was implemented in VA hospitals nation-wide; VistA has helped the VA cut its health care costs by 32 percent since 1996; and the VistA computerized prescription system is incredibly accurate, correctly matching patients and medication 99.997 percent of the time. It makes little sense to ignore this homegrown asset when setting out to build a broader DoD EMR system. Worse still, AHLTA can’t even communicate with VistA, adding a new layer of dysfunction to the military’s IT development.

This is all incredibly foolish, but maybe the real kicker is that AHLTA is proving a total failure. Not only is it a waste from an IT development stand-point, but it’s also proven to be a hindrance to the very military clinicians whom it’s supposed to be helping.

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It’s always worth exploring how health care works in other countries, if for no other reason than that models in other countries give us the chance to see how some of the approaches discussed by American reformers might pan out. What do the experiences of Germany and Netherlands tell us about the possibility of a better mixed public-private system in the United States? How is China’s health care system a cautionary tale of market forces gone wild? The answer to these questions can add to—or detract from—the appeal of certain health care strategies in the U.S.

It’s hard to imagine a country that could provide a more valuable example than Singapore. The Southeast Asian city-state is widely regarded as a health care superstar, especially when compared to the United States. Life expectancy at birth in the U.S. is 78 years; in Singapore, it’s 82 years. The Singaporean infant mortality rate is a mere 2.3 deaths per 1,000 live births, versus 6.4 in the U.S. As some have noted, these trends persist despite the fact that the U.S. has far more caregivers: 2.6 physicians per 1,000 people, compared with 1.4 physicians in Singapore. The United States has 9.4 nurses per 1,000 people; Singapore, just 4.2. Last—but certainly not least—is the issue of spending: the U.S. spends almost 16 percent of its GDP on health care, while Singapore spends a mere 3.7 percent. 

For reformers eager to cite examples proving that their health care ideals are a formula for success, Singapore offers a powerful case study. Its population is healthy, its system isn’t overloaded by medical professionals, and health care spending doesn’t gobble up a huge chunk of its economy. 

So how does Singapore do it?

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In the July 28th issue of The New Yorker you’ll find an entertaining story by David Samuels that explores the economy of pot in California, where medical marijuana has been legal since 1996. Focusing on the supply and distribution chains that help to get pot in the hands of patients, Samuels weaves a colorful yarn, but one that focuses heavily—and somewhat derisively—on the personalities involved. Given the author’s emphasis on the stereotypical stonerdom surrounding legalization, the casual reader may come away thinking that medical marijuana is just another hippie cause, a 60s-style cultural crusade rather than a question of health care. But that’s not the case. 

Aging Hippies

Samuels’ account of the medical marijuana industry boasts quite a cast. There’s “Captain Blue,” a middle-aged grower with “black and greasy hair” and ill-fitting tee-shirts that “expose his round belly.” He sells weed to dispensaries that supply medicinal marijuana. Then there’s “Lily,” who transports ganja “from Northern California to Blue’s apartment” in the trunk of her car, and a woman named “Cindy 99” who runs a dispensary and who looks like an “adolescent boy’s fantasy of his best friend’s hot older sister.” Finally let’s not forget “Dr. Dean,” the free-wheeling M.D. who regularly prescribes marijuana thanks to a watershed night at his friends’ where he was introduced to marijuana via spiked lollipops and brownies. “It was like Amsterdam,” he dreamily tells Samuels.

If these sound like the characters from a teen stoner movie, that’s certainly the way that they’re represented by Samuels. With such an emphasis on the weed enthusiasts, it’s perhaps unsurprising that the author’s big conclusion about medical marijuana is that it’s just another way to keep the pseudo-subversive indulgences of the 1960s alive. “The legalization of medical marijuana has allowed for the illusion that farming pot can provide opportunities for travel and cool art projects and personal growth,” says Samuels. He then concludes that for aging hippies, “growing ganja lets you feel that you’re still living on the edge,” particularly if you’re a washed-up, wannabe political radical.   

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In my recent post on the issue of quality in health care, I spoke a little about how public opinion can be a poor guide when it comes to understanding the full scope of our health care problems. I noted that, according to Gallup polls, 85 percent of Americans report being satisfied with the quality of care they receive—despite the fact that patients get, on average, just 55 percent of the care that experts recommend for most major medical conditions. The lesson here is clear: if you really want to improve health care in the U.S., you need to look beyond superficial preferences and into the nitty-gritty of how health care is delivered in our system.

This holds true for the issue that Americans care about the most when it comes to health care: making their own care more affordable. But it’s not the public that’s at fault here; when it comes to questions of cost and affordability, people just aren’t being asked the right questions.

Consider the Gallup poll mentioned above, which asked how people felt about the cost and quality of health care. 45 percent of those polled said they were dissatisfied with our health care system’s performance in terms of quality; just 15 percent said the same of their personal experience. In contrast, a whopping 80 percent of respondents said they were dissatisfied with the system’s performance in terms of cost, and 40 percent said the same of their personal experience. Simple enough, right?

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The ever-insightful Commonwealth Fund has just released its 2008 National Scorecard on Health System Performance, and reports that “the U.S. health system continues to fall far short of what is attainable, especially given the resources invested. Across 37 core indicators of performance, the U.S. achieves an overall score of 65 out of a possible 100 when comparing national averages with U.S. and international performance benchmarks.” According to Commonwealth’s metrics, overall performance has not improved since 2006.

As we mentioned recently, measuring performance in health care is a tough proposition, so it’s worth discussing Commonwealth’s rating system. The Scorecard looks at five components of what we might call "high-performance health care": healthy lives (preventable mortality & disability), quality (whether care is effective, coordinated, safe, and timely), access, efficiency (waste, appropriateness of care, administrative costs), and equity (disparities of care).

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It’s safe to say that Americans realize our health care system is in trouble. In polls, people cite paying for health care costs as one of their three most serious economic problems and consistently rank it as a top national priority behind the general economy, gas prices, and Iraq.  Earlier this month a Harris Interactive Survey found that a full one-third of Americans want to rebuild their health care system from scratch, a greater proportion than any European country. Finally, it seems that the American people have disabused themselves of the notion that the U.S. has the best health care in the world.

Or have they? While people may agree that too many Americans are uninsured and that health care costs too much, they still tend to think that the quality of care people receive—regardless how many people actually get it –is top-notch. This is a misconception that goes more or less unaddressed in the mainstream health care debate. That’s a sad omission: if we don’t talk about quality as a separate variable—and understand the reality of our system’s poor performance—we’re going to miss out on a big piece of the health care puzzle.

In May, the New England Journal of Medicine
(NEJM) printed a graphical representation of two Gallup polls from
November 2006 and 2007. The poll results show a deep “split between
public dissatisfaction with the overall system’s performance and
patients’ satisfaction with personal health care. (See below).

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This post was written by Niko Karvounis and Maggie Mahar

At a health care forum held last year in Las Vegas, then-presidential candidate Hillary Clinton declared that she was intent on "taking money away from people who make out really well right now” in order to fund health care reform. When asked exactly which fat cats she was referring to, Clinton responded: “well, let’s start with the insurance companies.”

Clinton’s sentiment—that private insurers are making out like bandits while our health care system crumbles—is part of the received wisdom these days, especially amongst progressives who believe that for-profit health insurance doesn’t add much value to our health care system. But the reality is that in recent years, private insurers haven’t been doing so well financially.

Consider United Health Care (UHC), the nation’s biggest private insurer. Joe Paduda of Managed Care Matters reports that UHC will be cutting 4,000 jobs as part of a restructuring plan that includes eliminating Uniprise, one of its major brands. Since last fall, UHC stock has plummeted from $53 to $22 a share. WellPoint, another huge private insurer, has watched its stock drop from $82 a share in 2007 to $49 a share in June.

As Robert Laszewski wrote on the Health Care Policy and Marketplace Review in April,  “Wall Street finally seems to be figuring out that the health insurance business is, and has been for years, on a long walk off a short pier. What’s sustainable about a business whose costs have continually exploded at 2-3 times the growth rate of the rest of the economy or the wage rate? Just where did Wall Street think this business was headed all those years the sector has been the darling of Wall Street?”

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Back in April, the Journal of Rural Medicine published an article that spelled out some of the ways in which rural medicine is a tough gig: Rural primary care physicians “tend to work longer hours, complete more patient visits, and have a much greater proportion of Medicaid patients” than urban physicians. Worse still, “[a]fter adjusting for work effort, physician characteristics, and practice characteristics, primary care physicians who practice in rural settings made $9,585 (5%) less than their urban counterparts."

So being a doctor in a rural region means less pay, longer hours (anywhere from 4 to 10 percent longer per week than urban doctors), and more Medicaid patients—none of which is particularly appealing to doctors.  (As I noted last year, reimbursement rates for Medicaid are abysmally low across the nation). At this point you may be thinking that this sounds like a warning to anyone even thinking about becoming a rural doctor.

Income

Not so fast. According to the Center for Studying Health System Change, the notion that the average rural doctor earns less is, well, what you might call an urban myth. While the Journal of Rural Medicine (JRM) looked only at primary care physicians and concluded that they make 5 percent less than their urban counterparts, CSHSC’s study of all physicians in rural practice tells a slightly different story.

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Health Wonk Review, a compendium of some of the best health care blog posts of the past two weeks, is up at the ever-informative Health Affairs blog. Be sure to check it out.