Summary: A report from the Congressional Budget Office (CBO) that came out last week spurred a flurry of headlines suggesting that fat people are responsible for the high cost of health care in America. “CBO– Obesity Will Decimate Future Health Costs and Care,” blared one headline. The story began: “While our nation’s obesity problem has trashed health care and insurance rates, the worst is yet to come.” In other words: forget about reform. Folks who eat too much will wipe out any savings.

It is true that obesity has become epidemic. As the CBO study points out, “From 1987 to 2007 the share of adult Americans who are obese has more than doubled –from 13 percent to 28 percent.” Over the same span, the amount that we spend on health problems associated with obesity has soared: “health care spending per adult grew substantially in all weight categories between 1987 and 2007,” the researchers write, but “the rate of growth was much more rapid among the obese. Spending per capita for obese adults exceeded spending for adults of normal weight by about 8 percent in 1987 and by about 38% in 2007.”

It is easy to assume this means that the rise in the percentage of Americans who sport a body-mass index (BMI) equal to or greater than 30, accounts for roughly one-third of the rise in health care spending. But that is not what the report says.

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Over at The HealthCare Blog (THCB), Michael Millenson, president of Health Quality Advisors and author of the critically acclaimed Demanding Medical Excellence: Doctors and Accountability in the Information Age, offers a fabulous account of the “Tonsillectomy Riots”  You will find it here: http://www.thehealthcareblog.com/the_health_care_blog/2010/09/remembering-the-tonsillectomy-riots.html

Millenson found the story on Tablet, an online magazine of Jewish news and culture, which, he writes, had rescued the tale “from historical obscurity. Piecing together old newspaper accounts in English and Yiddish, the magazine told what happened on New York’s heavily Jewish Lower East Side on a steamy day in June [1906] when 50,000 immigrant mothers descended on their local public schools demanding to see their children, having heard that there was a Board of Health-sanctioned child slaughter taking place.’”

In fact, the children in that particular school were in no danger. But the parents had reason to be worried. Tablet explains: “After tonsillitis reportedly kept scores of Jewish students out of school,  principal recommended the children have tonsillectomies.”  (“The idea of a contagious sore throat was apparently not part of folk wisdom at the time,” Millenson observes.)  

According to  the Tablet “When mothers complained they couldn’t afford either the doctor’s fee or taking time off to go see one, physicians were asked to perform tonsillectomies at the schools. Days before the riot, doctors had performed 83 tonsillectomies at one elementary school. That’s when the trouble began.

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Summary: Health care reformers have been promoting access to primary care as the answer to lifting the quality of care. If we had more primary care physicians, patients would be able to see them on a regular basis, and they would be less likely to wind up in the hospital–or so the theory goes.  But it’s not quite that simple.

A  report released today by Dartmouth’s Institute for Health Policy & Clinical Practice reveals that when it comes to managing chronic diseases Medicare beneficiaries  who live in regions of the country where patients typically receive more primary care, fare no better than patients in other regions.  This suggests that while primary care is important, it is effective only if it is part of a larger system of coordinated care. 

More primary care is not necessarily better care. That’s the first surprise. The second is that there is no simple relationship between the number of primary care physicians in a given area and the share of patients who see an internist on a regular basis. In fact, the study shows “no correlation” between the “supply” of primary care doctors and access” to primary care. In cities such as Boston, where the number of internists per capita is high, patients still have a hard time making an appointment. This may be because physicians are seeing their regular patients more often—leaving little room in their appointment books for new patients.

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Summary: Below, a story from Pulse—Voice from the Heart of Medicine, an online magazine that publishes true first-person stories and poems about the reality of illness and healing.

The story below raises some questions in my mind. Is this a case of humanity being trumped by the “technological imperative” –i..e, “if you have the technology you must use it”? Or was the trauma surgeon correct in reaching for the ventricular fibrillator, making a difficult, but necessary split-second decision to try to save the mother first?

On the other hand, he paid no attention to the chief resident. Was he too aggressive, too certain that he, alone, knew what to do?  Certainly, he wasn’t practicing medicine as a team sport. . .

Perhaps the answer is to look beyond the either/or. . . .See my comment at the end of the story.

I’d welcome responses from nurses, residents, doctors, medical students and patients.

To learn more about Pulse, click here : http://www.pulsemagazine.org/story.cfm?dropdown_us=1

 Broken

 Jordan Grumet

I was a third-year medical student in the first week of my obstetrics rotation. The obstetrics program was known to be high-pressure, its residents among the best. Mostly women, they were a hard-core group–smart, efficient, motivated–and they scared the heck out of us medical students.

I remember the day clearly: Not only was I on call, but I was assigned to the chief resident's team. I felt petrified.

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Guest Post by Dr. Chris Johnson

See his website (www.chrisjohnsonmd.com)

 Summary: Physicians under 40 are not the only ones adapting to EMRS. Veteran physicians also are making the transition. For many years, Chris Johnson was Director of the Pediatric Critical Care Service at the Mayo Clinic in Rochester, Minnesota, and Professor of Pediatrics at Mayo Medical School. He now practices in Santa Fe, New Mexico.  (Johnson is the author of three books, including Your Critically Ill Child:  Life and Death Choices Parents Must Face, 2007 and How Your Child Heals: An Inside Look at Common Childhood Ailments , 2001).

Johnson recognizes that we are “a long way from recognizing the brave promises of the EMR.”  Because there is no standard platform, he writes, “I’ve had to learn several, because different facilities choose different vendors. In our pluralistic medical system (if one can indeed call it a system), it’s a free-for-all. And each of them has its own maddening quirks.  . . . The computer whizzes who design the software don’t always seem to me to have quite the same goals as we doctors who use it.”

Nevertheless, he writes: “I find the EMR to be a powerful addition to my practice. In fact, I think I’m a better doctor for using it. I think a key reason for that is because of what I practice – critical care medicine

 At the same time, Johnson acknowledges friends in other specialties “who hate the EMR.”

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The news on Monday that one in six Americans are now enrolled in government poverty programs (Medicaid, food stamps, unemployment insurance and welfare) was an unsettling reminder of the economic fix we currently are in. Medicaid, as I’ve written before is now serving 50 million Americans, up at least 17% from when the recession began in 2007.

With a short-term, but ultimately inadequate, fix coming in the guise of Congress' $26 billion grant to states that extends federal increases in Medicaid funding that were part of the stimulus package, imminent disaster may have been averted. But according to Michael O’Grady and Jennifer Baxendell Young, both of whom served in senior positions at the Department of Health and Human Services before becoming policy consultants, it’s time to consider a longer term fix for a fundamental flaw in Medicaid financing. Writing on the Health Affairs blog, O’Grady and Young explain:

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Summary: Rick Scott, the former hospital executive who is now a candidate to become Governor of Florida epitomizes the power that concentrated  wealth now has to influence American politics—and, perhaps, buy elections. As Jane Mayer explains in her superb New Yorker piece about the multi-billionaire Koch brothers: “they are trying to shape and control and channel the populist uprising into their own [libertarian] politics… They are out to destroy progressives.”

Of course there are real questions as to whether the “populist uprising” of tea-baggers is a genuine grass-roots movement– or a made-for-TV spectacle produced, directed and funded by conservative wealth. But what is certain is that Rick Scott, like the Koch brothers, is using it to present himself as a politician who represents the will of the people.

The Koch brothers operate in the shadows. Rick Scott has stepped into  the limelight. But their goals are the same. To  advance a conservative agenda  and “break Obama.”  That also means killing health care reform.

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The most recent Health Wonk Review, hosted by Joe Paduda at Managed Care Matters, raises provocative questions about making health care reform a reality. You’ll find Paduda’s round-up of some of the meatiest health care posts that have appeared on the blogosphere in recent weeks here:  http://www.joepaduda.com/archives/001888.html

Below, a summary of just a few posts, with my thoughts on the topics.  If I had more time, I would write about all of them. I urge you to check out the entire Review.

                                           Gawande: “All Health Care Is Local”

 Paduda begins by highlighting Boston Health News, where Tinker Ready quotes Dr. Atul Gawande saying that “all health care is local.” Ready reports that at a recent health care quality colloquium at Harvard, “Gawande made the case for locally driven reform . . .. Communities, he said, need to find ways to create working systems out of the complex, fragmented elements of medicine.” See Ready’s post here http://tinkerready.wordpress.com/2010/08/17/bhn-exclusive-gawande-on-reform-all-health-care-is-local/

I agree.  When it comes to health care reform, different strategies will work in different regions. In some places, Accountable Care Organizations will thrive; in other medical cultures, doctors will reject the idea of working on salary for a large organization, though they may be willing to take responsibility for outcomes by being paid a lump sum each year to keep a patient well (capitated care.)  In other cities, newly expanded community clinics will succeed in becoming “medical homes.”  In most states, experience suggests that Nurse Practitioners will be accepted (by both patients and doctors) as primary care providers. But in other places physicians and patients just won’t be comfortable with the idea.

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Summary: When I wrote Money-Driven Medicine, the Real Reason Health Care Costs So Much (Harper Collins, 2006),  Rick Scott stood out as one of the more memorable characters in a  rogues’ gallery of CEOs who helped create the stock market bubble of the 1990s.

This week, Rick Scott beat Florida Attorney General Bill McCollumn to win the Republican party’s nomination for governor, shattering campaign spending records by investing $50 million of his own money in the race.  Yesterday, in an interview with CNN, Scott said there is no limit on how much of his own money he would spend in the upcoming election.

The citizens of Florida might want to ask: Where did that money come from?

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Below, an excerpt from an imaginary dialogue between Rick Scott and Rick Scott’s “inner voice”  from Warren Langer’s blog “Still liberal at 83” http://stillliberalat83.net/2010/06/28/rick-scott-republican-candidate-for-florida-governor-talks-to-rick-scott/

It seems, to me, to capture Scott’s inner spirit in an important way.

Rick Scott, Republican Candidate for Florida Governor, talks to Rick Scott

Inner voice: What’s happening handsome?

Scott:         I’ve been thinking of taking over Florida. It’s broken and broke and I can pick it up cheap.

IV:              Peanuts cheap?

Scott:        A few TV spots, some snappy phrases and it’s mine. A state of my own.

IV:              Didn’t you have some problems with that chain of hospitals you ran?

Scott:         I already apologized; said I was the Chief Executive Officer and I was responsible.

IV:             Columbia HCA was fined $1.7 billion for Medicaid and Medicare fraud. Isn’t that a problem?

Scott:         I apologized.

IV:             And that’s it?

Scott:        Hey I not only apologized but said, “Let’s get to work.”

IV:             And that will do it?

Scott:        Look pal, Florida is a state with a collective IQ of 70. They don’t know from Medicare, Medicaid and Quantum Physics which may help in the bathroom. They want me, the next governor, the handsome bald guy, to fix potholes and have slot machines in every condo except for Lake City where they and I are against gambling of any kind except bingo.

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