When President Obama named Dr. Donald Berwick to head the Centers for Medicare and Medicaid (CMS) last March, I wrote this:

“Most who know Berwick describe him a ‘visionary’ and a ‘healer,’ a man able to survey the fragments of a broken health care system and imagine how they could be made whole.  He’s a revolutionary, but he doesn’t rattle cages. He’s not arrogant, and he’s not advocating a government takeover of U.S. health care.”

To understand what I meant, view these clips from the film, Money-Driven Medicine, where Berwick speaks about the need for healthcare reform. Soft-spoken and charismatic, Berwick is as passionate as he is original. His style is colloquial, intimate, and ultimately absolutely riveting. He draws you into his vision, moving your mind from where it was to where it could be.

And now, it appears that we are going to lose him. Thursday, 42 Senators delivered a letter to President Obama demanding that he withdraw his support for Berwick to head CMS. The Boston pediatrician and co-founder of the Institute for Health Care Improvement (IHI) had received a temporary appointment in July while Congress was on vacation. President Obama re-nominated him in January. But Berwick still needs to be confirmed by the Senate, or he will have to leave his post at the end of this year.

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Danielle and Robb Deaver are living proof of the awful reality of Nebraska’s ill-conceived “fetal pain” law. The law, which took effect last October and is the only one of its kind in America, prohibits abortions in the state after the 20th week of pregnancy. It is based on the discredited notion that a fetus may feel pain at that stage of development. Physicians who break the law face felony charges that could result in five years in prison and a $10,000 fine.

Danielle Deaver, a nurse, was 22 weeks pregnant with her second child when her water broke. Doctors determined that her membranes had ruptured and there wasn’t enough amniotic fluid to support the fetus.But because of Nebraska’s law, Deaver could not obtain an abortion and was forced to live through “10 excruciating days” waiting for her extremely premature fetus to be born even though doctors were sure it would never survive. When finally delivered, the one-pound, ten-ounce baby girl gasped and struggled for air, dying 15 minutes later in her mother’s arms. Tragically, the Deavers had sought an abortion to avoid just such an excruciating end; they were concerned that the infant would suffer while it died, trying to breathe.

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It’s always good to hear about the FDA being proactive. Below, a post by Jim Edwards, writing on BNET’s  “Placebo Effect, ” tells how the FDA reacted when surgeons began advising doctors that they shouldn’t use the word “cancer” when talking about a form of breast cancer associated with breast implants.  

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When is breast cancer not “cancer,” not malignant and not a tumor? When you’re a plastic surgeon trade group funded by implant makers Allergan (AGN) and Johnson & Johnson (JNJ), according to an exchange of letters between watchdog group Public Citizen and the FDA.

In January, the FDA warned of an unusual type of breast cancer associated with implants. Allergan, which makes the Natrelle brand of implants, responded by denying that implants were linked to cancer and by denying that anaplastic large cell lymphoma (ALCL) is “cancer” per se.

On Feb. 3, the presidents of two cosmetic surgery trade groups — The American Society of Plastic Surgeons and The American Society for Aesthetic Plastic Surgery held a members-only webinar where they advised doctors on what to say to worried women. Dr. Phil Haeck, president of ASPS, said ALCL wasn’t a “cancer” but a “condition”:

“[Y]es it’s classically a malignant tumor, but it has such a benign course that when we were discussing ways to talk to the media we decided that we would call this a condition  . . .not a tumor, not a disease and certainly not a malignancy. . . .

“And I would recommend that you use the same terms with your patients rather than disturb them by saying  ‘this is a cancer.’   . . .The best word is “this is a condition.’  If you develop this condition here’s how we are going to treat it, the way we are going to diagnose this condition is this . .. .

And I think you are certainly justified, with what we know now, in downplaying the malignant potential of these [cancers].

The FDA responded by having a little chat with the two groups and the video of the webinar has magically disappeared from the groups’ web sites.

Following the money

It is probably not a coincidence that ASPSS and ASAPS repeated the cancer-denial line first promulgated by Allergan: Both organizations have received funding from the company. ASPSS has also received funding from Allergan’s main competitor, J&J, which makes the Mentor implant line. (Mentor’s reaction to the FDA warning was more muted than Allergan’s but its statement also avoided mentioning the C-word.)

Both Allergan and J&J fund provide funds for ASPSS, as noted on its web site.

At ASAPS, Allergan’s funding is more indirect. It has supplied research grants through ASAPS’ research arm, the Aesthetic Surgery Education and Research Foundation. You can see those grant award announcements by searching for “Allergan” here.

The two groups ought to be ashamed of themselves. It is one thing to take funding from drug and device companies . .  . . But the groups ought to represent the medical expertise of the healthcare providers who are their members, not the PR agendas of two companies who are afraid they may lose money from too much blunt but accurate talk about breast cancer.

Roughly 65 million Americans live in places where there are at least 2,000 potential patients for each lonely physician. No surprise, these tend to be impoverished rural regions, or depressed inner cities. We call them “underserved areas.”

If we paid medical schools to train more primary care physicians, would they migrate to these areas? Probably not. Experience shows that if we increase residency slots, physicians continue to flock to the same popular, well-served areas where most prefer to settle: Manhattan, Boston, Boca Raton. . .

It should come as no surprise that relatively few med students elect to set up a practice in rural Mississippi, Detroit, or the South Bronx—unless they are returning home. As I have written in the past, research reveals that students coming from low-income communities frequently feel a commitment to those communities.  

Many—not all, but enough—want to go back. But these days, given the sky-high cost of medical school tuition, combined with the nearly perfect test scores and GPAs that med schools require, very few students who attended public school in a small town in Tennessee wind up becoming M.D.s. 
Yet health care reform guarantees that waiting rooms full of formerly uninsured low-income patients will be looking for health care. According to the Harvard Medical School, an additional 17,000 primary care health professionals will be needed in underserved areas. Skeptics suggest that reformers have promised more than we can possibly afford. How will we funnel more general practitioners to areas where there already are too few physicians? How much will we have to pay to lure them there?

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It seems old lies never die—especially when it comes to entitlement programs for the poor.

In the contentious debate over how to reduce spending in state Medicaid programs, Mississippi Gov. Haley Barbour (R) insisted that one solution for his state is to have Medicaid recipients pay a larger share of their medication costs, saying, "We have people pull up at the pharmacy window in a BMW and say they can't afford their co-payment."

That ridiculous comment harkens back to Ronald Reagan’s use of "Cadillac-driving welfare queens," to refer to a fictitious cadre of black mothers living the high life while collecting public assistance. Tinged with racial undertones, Reagan’s characterization of welfare recipients—including a 1976 reference to the typical food-stamp user in the South being  a ‘strapping young buck’ buying T-bone steaks—helped bolster support for his overall attack on social welfare.

As Steve Benen writes in Washington Monthly today, “In other words, when Barbour claims ‘we have people’ who pick up prescriptions in Mississippi in a BMW — as if this is somehow common — he's lying.

“But I suspect Barbour doesn't much care. The point of a quote like that one isn't to draw attention to a legitimate policy concern; it's to appeal to right-wing voters on an emotional level.”

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States want flexibility in implementing the health care law, and President Obama told the National Governor’s Association yesterday that he supported a bipartisan bill that would allow states to apply for innovation waivers in 2014 instead of in 2017, as currently written into the health law. This bill, introduced last year by Sens. Ron Wyden (D-Ore.) and Scott Brown (R-Mass.) would allow states to opt out of major provisions like the individual mandate and pursue alternative routes to reform—as long as they meet the same coverage targets as the federal plan. Kathleen Sebelius, Secretary of the Department of Health and Human Services, called this action “another crucial step in empowering states to lead,” giving Vermont, for example, a chance to try a single-payer approach at the same time that Utah was developing a market-driven insurance exchange.

Meanwhile, Obama’s announcement was greeted far less enthusiastically by conservative critics of the health law who are intent on repealing the entire legislation, not making it more innovative. “Mandating many of the same requirements, this plan would treat states as agents of the very law these governors are running away from,” said Michael Steel, spokesman for Speaker John Boehner. “A better approach would be working with reform-minded governors to give states more flexibility to lower health care costs immediately by, for example, fixing costly federal regulations on Medicaid.” This chilly reception doesn’t bode well for the Wyden-Brown bill’s chances in the House.

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When I was in my twenties, I was diagnosed with glaucoma. At the time, I didn’t worry about it. I was twenty-something, busy teaching, having babies, writing a book—and, with glasses, my eyesight was 20/20.

It was only when I moved to Manhattan twenty-five years ago that I began to take the disease seriously. A friend recommended an ophthalmologist who, I was told, was one of the best in the city. He regularly turned up on lists of New York’s star specialists, had an office on Park Avenue, and didn’t take insurance of any kind. Twenty-five years ago, this was unusual. But, my employer’s insurance was generous and paid most of his very high fee.

At my first appointment, I mentioned the early diagnosis of glaucoma. After examining my eyes, Dr. X told me that that I must begin using eye drops immediately. I also should begin making appointments to see him every four months so that he could check the “pressure” on my optic nerve. Glaucoma is the second leading cause of blindness in the U.S. There is no cure, but usually it can be controlled with eye drops. “It must be watched carefully,” said Dr. X. 

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Gary Schwitzer writes on his blog “Health News Review” that he was “jolted” by a television commercial he saw recently for an artificial hip joint sold by medical device-maker Smith & Nephew.

The ad features athletic, fit, male body forms engaged in all sorts of strenuous pursuits; playing soccer, surfing, rock climbing up a craggy peak (!). The figures are rendered as stylized silhouettes but if I had to guess, I’d say they were designed with highly active men, age 40 to 50, in mind. Triatheletes and Ironmen wouldn’t be a stretch.

As Schwitzer notes, “it struck me that this younger demographic was the sole focus of the figures depicted in the commercial.”

Schwitzer would be right. The Smith & Nephew hip implant, called the Birmingham Hip Resurfacing System, is a newer kind of device that replaces just the damaged joint surfaces; not the complete joint. The femoral head is shaved down and covered by a metal cap and the hip socket is replaced with a metal cup. This procedure preserves some 3-4 inches more of the thigh bone than traditional total hip replacements. It’s being marketed as an alternative for active, younger patients (under 60) who are likely to outlive the implant and will need a total hip replacement 15 or 20 years down the road. By preserving more of the original joint, the theory is that the second surgery will be easier to perform and more successful. Two other companies now sell similar products; the Cormet Hip Resurfacing device (sold by Stryker) was approved by the FDA in 2007 and the Conserve Plus implant (sold by Wright Medical Group) got the nod in 2009.

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This fortnight’s Health Wonk Review is hosted by Louise Norris of the Colorado Long Term Care Insider who has done an excellent job of rounding up some of the most provocative health care posts published in the past two weeks.

Writing on the Incidental Economist, Austin Frakt explains that if we rein in health care spending, we have to go where the money is. And that is not in the health insurance industry. Insurance premiums are so high, in large part, because reimbursements to health care providers have been sky-rocketing, along with payments to drug-makers and device-makers.

“In each of the past 50 years payment to health care providers has accounted for more than 85 percent of health insurance premiums,” Frakt points out. “Thus, only a small fraction of spending on health insurance premiums is consumed as a cost of insurance. I have no doubt that there are ways to squeeze some efficiency out of the insurance system. But doing so is not likely to make a substantial, long-term impact on the inflation of health care costs.

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It’s open season in Congress on women’s reproductive rights. The Pence, Pitts and Smith trio of conservative Congressmen have been using gruesome depictions of abortion, charges of child-abuse (against fetuses), and other inflammatory tactics to help whip up support for their three separate pieces of anti-choice legislation.

Today, rhetoric grabbed the spotlight when the House voted 240-185 to pass Rep. Mike Pence’s (R-IN) amendment to specifically cut off all federal funding for Planned Parenthood, the 95-year-old women’s family-planning stalwart that he calls a “criminal enterprise.” The House vote is "a victory for taxpayers and a victory for life,” according to Pence who has had his sights on Planned Parenthood for years now. In fact, Pence’s amendment is a redundant, mean-spirited piece of legislation that is designed to not only block women’s access to a legal medical procedure, but is also aimed at preventing women from getting contraceptives, counseling, HIV testing and basic gynecological care.

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