Below, a guest-post by David Spero, R.N.  Spero is the author of Diabetes: Sugar-Coated Crisis  — Who Gets It, Who Profits and How to Stop It, a book that Thomas Bodenheimer MD, Professor of Family and Community Medicine, University of California, San Francisco describes as “a hard-hitting and beautifully written look at the social causes and cures of chronic illness… illuminates the true reality of diabetes and provides cutting-edge ideas on prevention and treatment.” (Bodenheimer’s recommendation puts it on my “to-read” list.)

In this post, Spero explains why “free market competition” doesn’t work to bring us affordable health care. Quite simply, the seller has too much power. Drug-makers and device-makers set their own prices, with little push-back from public-sector or private sector payers. Lobbyists have managed to push through a law stipulating that Medicare cannot negotiate for lower drug prices. As for private insurers, they have found that if they don’t cover all of the drugs advertised on TV, they lose customers. So for the past ten years they have been shelling out whatever the manufacturer demands, while passing the cost on in the form of higher premiums.

In the case of doctors and hospitals the situation is more complicated.  As I explain in a note following Spero’s post, total reimbursements to providers have been spiraling–though some physicians and medical centers have enjoyed the lion’s share of the gains, while others have watched their income drop.

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Shock and outrage ensue every time the press gets wind of the million-dollar-plus salaries and other perks reaped by some CEOs at nonprofit hospitals. This year is no different—except that the ongoing recession that is forcing states to make painful budget cuts, especially by slashing Medicaid programs, is making the compensation reports especially hard to stomach.

In New York, for example, a state Medicaid-redesign commission recently recommended cuts to health care spending that total $2 billion. But while the proposal includes limiting home health care, increasing co-pays for Medicaid recipients, reducing their dental and mental health services, and putting a $250,000 cap on malpractice claims, there was no mention of limiting what the New York Times calls “lofty” salaries for CEOs at nonprofit hospitals.

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A hospital’s Chief Medical Information Office (CMIO) should be a physician, says Pam Brier, president and CEO of Maimonides Medical Center “because nobody knows a doctor’s business like a doctor.” 
As a hospital’s information technology (IT) point person, a CMIO needs to be able to persuade physicians and other health care professionals that health information technology (HIT) can help them care for patients.

It is not that Brier believes that non-physician managers can’t talk to doctors. . . After all, she herself is not an M.D. Yet she runs Maimonides, a top-ranked 700- bed teaching hospital in Brooklyn, New York.

On the other hand, Brier is not an MBA either. She has a master’s in Health Administration, which means that, unlike many hospital CEOs who went to graduate school to study business, she understands that an organization that provides health care is not a “business” in any ordinary sense of the word. A hospital is a service organization: its raison d’etre is to meet the needs of a community and its patients.

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There are many serious problems with the current U.S. mental health system, the most glaring being the over-use or misuse of psychiatric drugs, the warehousing of the mentally ill to prisons and emergency rooms, and the unholy connection between academic researchers and pharmaceutical companies that can result in stilted clinical trials of already-approved drugs and misleading efficacy information that is used to boost sales.

I have written about these issues on HealthBeat before, but no single case demonstrates the convergence of these problems better than the tragic story of Dan Markingson, a young man who suffered his first bout of severe psychosis and schizophrenia in the summer of 2003. In November of that year, Markingson was taken to the University of Minnesota Medical Center in Fairview and against his mother’s wishes, was enrolled into an industry-sponsored drug trial being run by his psychiatrist, Dr. Stephen Olson. Six months later on May 8, 2004, mentally deteriorating and still enrolled in the study, Markingson, 27, committed suicide in the shower of his halfway house by violently stabbing himself in the neck, chest and abdomen.

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Below, an excerpt from a superb post by Bob Wachter, Associate Chairman of the Department of Medicine at the University of California, San Francisco, that was originally published on Wachte'r's World. There, he questions whether academic medical centers (AMCs) will be able to turn themselves into the accountable care organizations (ACOs) that reform legislation favors. Or as Wachter, puts it: "Are Academic  Medical Centers Toast in a Post-Healthcare Reform World?”

I believe that some AMCs will be able to “re-vision” themselves, and that this will be the best thing that ever happened to them. Many AMCs need to re-set their priorities, putting less emphasis on money-driven research, while focusing more of  their resources on safe, patient-centered care. As  Wachter,observes, this will mean changing the keenly competitive and often wasteful medical culture traditional at many AMCs.

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U.S. healthcare is awash in medical technology, and recently, in an editorial published on Bloomberg.com, one surgeon suggested that we may be drowning. For as Dr. Craig D. Turner, a urologist in Portland, Oregon points out “what is different with the new wave of technological marvels is that many are heavily driven by marketing; here he links to an ad by GE Health touting wide-bore MRIs “Simply Powerful, Powerfully Simple.”

New technology always poses risks, he points out, because it “requires that physicians master arduous new skills” which means that while doctors climb a steep learning curve, some patients may be hurt.  Someone has to be one of the first hundred patients a doctor learns on. Meanwhile, often, the new, new thing “lacks clear benefits compared with established and less-costly technology.”

Innovation is proceeding at a pace that helps drive waste: “One health-care administrator told me the basement of the hospital is full of million-dollar machines collecting dust — not because they didn’t work or because they were ineffective, but because they have been displaced by newer technology.”
“Now 10 years into surgical practice, I have learned some hard lessons related to new technologies,” Turner admits. “Patients often are put at greater risk as we physicians scale the learning curve. . . More things can go wrong.”

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Below an excerpt from an essay by Dr. Nortin Hadlerprofessor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and an attending rheumatologist at University of North Carolina Hospitals. He is the author of "Worried Sick: A Prescription for Health in an Overtreated America," "The Last Well Person," and “Stabbed in the Back.”

I am always delighted when Hadler contributes to HealthBeat. He is willing to tell the truth about medical evidence and comparative effectiveness research– even when candor may not be popular. You don’t have to agree with him, but without question, you should read his work.   Hadler is not a pundit offering one man’s opinion:  his writing is studded with footnotes and links to rigorous medical research.

This post is excerpted from a piece which originally appeared on ABC.com, Health Care Reform: The Difference Between Rationing and Rational.“There  Hadler explains why, if a doctor recommends angioplasty, you should ask some questions. At the end of the post, you will find my “Note” on what I find the most intriguing aspect of Hadler’s essay: how to win the healthcare lottery without buying a ticket.

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Below, another provocative story from Pulse–voices from the heart of medicine, an online magazine of personal experience in health care.  The piece raised some questions in my mind about how we train medical students. You’ll find my comments at the end. (To join the Pulse community, and receive every issue, online, at no cost, click here.)

First, Do No Harm

By Alison Block

It's one of my earliest memories: I'm wrestling with my brother, and I'm losing, because I'm five and he's seven, and he's bigger and stronger than I am. So I bite him, hard.

Instantly I know I've crossed some sort of line, and I employ my most primitive defense mechanism, shouting out, "He bit me! Jon bit me!" I feel shame, because I am old enough to know it is wrong to hurt people–and to lie.

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In his State of the Union speech in January, President Barack Obama appeared to throw a bone to congressional Republicans when he said, "I am willing to look at other ideas to bring down [health care] costs, including one that Republicans suggested last year – medical malpractice reform to rein in frivolous lawsuits." There were scattered cheers and clapping from the audience, but since then no more details have emerged from the President.

To those who need reminding, reforming medical malpractice is a cornerstone of the Republican version of health care redesign; one of the few concrete ideas they’ve put forth for reducing the nation’s $2.1 trillion health care bill. The idea, recently championed also by Gov. Andrew Cuomo’s (D-NY) Medicaid redesign team, is to cap non-economic damages (compensation for future pain, suffering and loss of function) at $250,000 in all cases. Some 30 states already have variations of medical malpractice caps and other tort reforms in place. According to the Congressional Budget Office, the effect of these caps on reducing the number of lawsuits or the practice of “defensive medicine” (unnecessary tests and procedures doctors order to avoid being sued) has been at best, equivocal. Where they have had a moderate effect is on lowering malpractice insurance premiums for certain types of physicians and increasing their supply in some geographic areas.

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"The Senate will never vote to confirm Dr. Donald Berwick as CMS administrator", Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee told reporters earlier today. According to Modern HealthCAre, Baucus said that he has discussed Berwick's nomination with Republican senators and they plan to oppose Berwick under any circumstances.

“Republicans won,” he said about the nomination. 

 For his part, Berwick told reporters that he was grateful for the White House support he has received since 42 Republican senators wrote President Barack Obama last week to demand that he withdraw Berwick from consideration. Earlier today, Modern HealthCare quoted Berwick saying that he is "focusing on the job."

For Republicans to flatly refuse to consider a presidential nominee without letting him testify at a confirmation hearing signals something far short of "bipartisan cooperation." 

Do they actuallly have that much power? 

Perhaps. But arrogance can be dangerous.

I find it hard to imagine that the Obama administration will roll over and say "Okay. We'll let forty-two senators decide who heads up Medicare." The gang of 42 do not  even represent a majority of the 100 elected representatives in the Senate. But of course, 60 votes would be needed to break a filibuster, which is why the group, led by Sen. Orrin Hatch, believe that they have the clout to pull this off.