Many Americans assume that all European health care systems are essentially the same: single-payer, government run systems that were created, from scratch, by wise and benevolent reformers.

Nothing could be further from the truth, as Harvard surgeon and author Dr. Atul Gawande reveals in the most recent issue of The New Yorker. 

In virtually every country, accidents of history have provided the foundation for reforms that are unique to each country.  “Reform” did not mean sweeping change. Instead, each country used the hand that history dealt it, and built upon the system it already had. Gawande suggests that the U.S. should do the same.

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Health Wonk Review, a round-up of some of the best of the last two weeks of healthcare bloggery is up on Jaan Sidorov’s Disease Management Care Blog. Sidorov has set his piece to music; to see what I mean click here.

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As you no doubt have heard, the healthcare blogosphere has been seriously divided on President Obama's nomination of CNN chief medical correspondent Dr. Sanja Gupta as our next surgeon general.

Over at The American Prospect, Ezra Klein liked the pick. Klein sees the surgeon general as "the country's leading medical and lifestyle educator," and it's that role " Klein wrote, that  "Gupta  is uniquely positioned to fill. There's not a doctor in this country with half his media training and experience, nor one with a rolodex of editors and reporters a tenth as large." Klein  also expects that Gupta will be an effective  advocate for the President' s health care plan."Sanjay Gupta, arguably the nation's most trusted health care authority, will be back on TV screens arguing for Obama's universal health care plan, lending it his credibility as a doctor, a trusted media presence, and the nation's surgeon general."

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       When President Obama said “The time has come to put away childish things,” I couldn’t help but recall healthcare reformer Don Berwick, sounding discouraged last winter, as he said “Maybe this country just isn’t mature enough for health care reform.”

         Berwick, who is the president of the Institute for Healthcare Improvement, was referring to the fact that at times, it seems that everyone wants healthcare for all—but no one wants to pay for it. And few want to hear about the trade-offs: that the young, healthy and wealthy will have to help pay for the poor, the old and the sick; that we will have to give up our unreasonable demand  for every test, treatment or drug that we think we want—or have heard of — even if there is no medical evidence that it works.  Most of all, we have to give up the unreasonable expectation that somehow, we can beat death—that if someone does die it’s because she ate too much, or the doctor made a mistake, or the HMO refused to give her that last miracle treatment.  We have come to think of death as an error.

        Turning to the economy, Obama suggested that most of us don’t yet realize what lies ahead: “we are in the midst of a crisis that is not well understood.”  He hints at the need for sacrifice: “it is ultimately the faith and determination of the American people upon which this nation relies. It is the kindness to take in a stranger when the levees break, the selflessness of workers who would rather cut their hours than see a friend lose their job which sees us through our darkest hours.”

        He also reminded us that the economy was weakened, not only by the greed of a few men, but by a “collective failure to make hard choices.”

       In his words, I heard an echo of JFK’s “And so, my fellow Americans: ask not what your country can do for you—ask what you can do for your country.”

       JFK’s speech was more original, and had a stronger cadence:

       “So let us begin anew—remembering on both sides that civility is not a sign of weakness, and sincerity is always subject to proof . . . .

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            \When Tom Daschle testified on the Hill earlier this month he reassured many by saying that as Health and Human Services Secretary, he would be working for healthcare reform “guided by evidence and effectiveness, not by ideology.”  Daschle, like Laszlewski, was suggesting that reform could and should be bi-partisan.  But as I suggested in part 1 of this post,  Daschle is only half-right. Medical evidence should guide our decisions about what to cover; but when it comes to questions of whom to cover—and how much coverage they should receive– we are going to have to wrestle with “ideology."

     For many, the word “ideology” carries negative connotations. This is in large part because,  during the Cold War, we used the word to refer to Communism.   Capitalism, we argued, was not an “ideology”—it was true.  But if you open the American Heritage Dictionary, you’ll find that the word itself is neutral: it simply means: “A set of doctrines or beliefs that form the basis of a political, economic, or other system.”   Those beliefs can be true or untrue.  “It is one of the minor ironies of modern intellectual history that the term "ideology" has itself become thoroughly ideologized,” observes the anthropologist Clifford Geertz in Ideology as a Cultural System. http://www.gongfa.com/geertz1.htm

        Granted, “a set of doctrines” sounds potentially rigid or “doctrinaire.” But there is nothing wrongheaded about having a “set of beliefs” about how a society or an economy should operate. Most of us do have convictions about what constitutes a just or an unjust society. And health care reform is about both those beliefs and science. We can try to sweep that under the rug, but I doubt we will get very far. In the debate over health care reform, differences in the ideas that conservatives and progressives hold dear will continue to crop up.

      Conservatives believe that “the market” can solve our healthcare problems. Progressives believe that you cannot count on “the market” to decide in favor of the public good.  I would add that “the market” is not moral or immoral; it is “amoral.” If we want a fair health care system, government is going to have to weigh in with laws and regulations that steer the system toward “the common good.”

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Over at Healthcare Policy and Marketplace Reform, Bob Laszewski reports that “the extension and expansion of the State Children's Health Insurance Program (SCHIP) has now passed the full House and the Senate Finance Committee and is on its way to the full Senate where it will undoubtedly also pass and then be reconciled with the similar House bill.

“However,” he warns, “the way it is being done does not give me a good feeling.

“In the Senate Finance Committee the Democrats were only able to get the support of one Republican–Maine's Olympia Snowe–on the way to a 12-7 approval.

“They did not have the support of the ranking Republican, Chuck Grassley of Iowa.”

Laszewski is worried: “Senate Finance Democrats lost the support of the Republicans when they insisted on departing from last year's bipartisan agreement to leave existing policy on covering the children of legal immigrants as is. As it now stands, a legal immigrant agrees not to apply for Medicaid and SCHIP benefits for the first five years they are in the country. Under the new rules states would have the option of covering legal immigrants. The new bill also left out provisions from the earlier bipartisan comprise to limit benefits for higher income families.

“Without judging on the merits whether these two new provisions should have been in the bill, what the Democrats have done is moved away from earlier bipartisan agreements,” he points out, “ and in doing so lost moderate Republicans like Grassley who showed good faith in reaching an earlier bipartisan compromise.”

He concludes: “As I have repeatedly said on this blog, major health care reform is not possible unless it is bipartisan.”

Here I have to disagree with Laszewski.  Inevitably, healthcare reform will be partisan because it is all about social values—and our beliefs about what is fair.  Progressives tend to emphasize a collective vision of the common good. Conservatives are more likely to stress the rights of the individual.

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Maggie recently wrote about a MedPAC decision aimed at stopping for-profit hospices from purposefully keeping patients under their care for extended periods of time in order bill Medicare for more days of service. Medicare’s concern that the hospices might be bilking the system raises a larger question: should we be worried that so many of today’s hospices are for-profit?

The short answer is “yes,” and at the very least, we should be giving them—and hospices in general—more attention. Hospices play a bigger role in our health care system than ever before. In 2005, hospices cared for 1.2 million patients, and one-third of Americans who passed away that year did so under hospice care. According to the National Hospice and Palliative Care Organization (NHPCO), hospice admissions are rising rising at a rate of almost 10 percent a year.

The fastest growing segment of the hospice industry is—you guessed it—for-profit hospices. Between 1994 and 2004, the number of for-profit hospices in the US increased nearly 4-fold, growing more than 6 times faster than nonprofit hospices. According to industry estimates, for-profit hospice programs now care for about 35% of hospice patients, versus a mere 9% in 1990 (today,  nonprofit groups care for 56% and the government and other types of organizations care for the remaining 9%). Little wonder, given that there’s so much money to be made in the industry:  Medicare reimbursement for hospice care has grown from $68.3 million in 1986 to $8.3 billion in 2005 and is expected to hit a whopping $45.6 billion by 2030.

The bad news is that, in their quest for Medicare dollars, for-profit hospices don’t provide all the care that they should in order to fulfill the hospice mission of maximizing patients’ quality of life. In fact, a 2004 Medical Care study of 2,080 patients enrolled in 422 hospices across the country found that “terminally ill patients who receive end-of-life care from for-profit hospice providers receive a full range of services only half the time compared with patients treated by nonprofit hospice organizations.” That’s because for-profit hospices like to keep costs low by skimping on services, particularly so-called “non-core” services like medications and personal care (How these are classified as “non-core” services I don’t know—they seem pretty important to me—but there you go). For example, families of patients receiving care from a for-profit hospice received counseling services, including bereavement counseling, only [45% as often] as those in a nonprofit hospice. Translation: when researchers controlled for differences across patients, sicknesses, and conditions, those at for-profit hospices were only half as likely to get the same support provided at nonprofit hospices. A 2005 follow-up study confirmed that for-profit patients receive a “narrower range of services” than nonprofit patients.

Given these results, the senior author of both studies, Dr. Elizabeth Bradley of Yale, concludes that “for-profit hospices…might not be as strongly rooted in…[the]…traditional hospice philosophy” of “psychosocial support, spiritual care, the use of volunteers and family, and symptom management” as their nonprofit counterparts.

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This post was written by Maggie Mahar and Niko Karvounis

2007 marked the first time in 50 years that less than 20% of Americans smoked.  This is the good news. The bad news is that, just as the battle against smoking has entered what may be its most critical, final phase, support for that battle has waned among policymakers—even though the problem is far from solved.

Tobacco use, especially cigarette smoking, continues to be the leading cause of preventable diseases in the United States. It is blamed for 435,000 premature deaths in this country each year, and it adds more than $75 billion to annual spending on health care, according to the federal Centers for Diseases Control and Prevention.

Consider the raw numbers: in 2007, an estimated 19.8% (43.4 million) of US adults were still smoking cigarettes; of these, 77.8% (33.8 million) smoked every day, and 22.2% (9.6 million) smoked some days.  That’s a lot of smoke.

Break down the demographics and you find stark patterns. Smokers are likely to have less education than other Americans: CDC research has found that adults who have a GED diploma (44.0%) and those with 9–11 years of education (33.3%) are most likely to use tobacco.  Americans with an undergraduate or graduate degree are least likely (11.4% and 6.2%, respectively). Poorer people also are more likely to smoke: 33% of U.S. adults living below the poverty level are smokers while only 23.5% of those living above that level still light up.

Given how expensive cigarettes are these days, these are striking statistics. Why do low-income people smoke? Medical research shows that being poor is extremely stressful. You have less control over your life and must cope with much more uncertainty: Will you be able to pay your rent? What will you do if you lose your job? Are your children safe walking home from school?  As anyone who has ever been addicted to tobacco knows, being anxious makes you reach for a cigarette.

Military veterans under the care of the Department of Veterans Affairs (VA) health care system are also more likely to smoke than other Americans. Indeed, a 2004 report titled “VA in the Vanguard: Building on Success in Smoking Cessation” points out that “the prevalence of smoking is approximately 43 percent higher” among these veterans than in the general population.  “Many Americans who may have never smoked prior to their military service began smoking while in the service,” the report observes.  In the past, “ ‘Smoke ‘em if you‘ve got ‘em’ was a common command, and in many cases was even encouraged as it was thought to help keep soldiers alert and awake—or to help them cope with the tedium of waiting while on watch and the stress of combat.”

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Today, the Kaiser Network reported that on Friday, the Medicare Payment Advisory Commission (MedPac) approved a set of recommendations that would revise the current Medicare payment system, which was implemented in 1983, for hospice care providers serving terminally ill patients.  CQ HealthBeat reports that these recommendations will be included in a report to be issued in March to Congress and to take effect in 2013. (Thanks to Brad F. for calling my attention to this piece of news.)

Apparently, MedPAC has been concerned that for-profit businesses have been driving growth in Medicare spending by targeting hospice patients who need relatively long periods of care. The new payment system intends to remove incentives for long hospice stays.

So MedPac is recommending that Medicare change its payment system to include relatively higher payments per day at the beginning of the episode, and relatively lower payments per day as the length of the episode increases. 

Call me cynical, but do you suppose that would give for-profit hospices and incentive to toss patients out and send them home if they linger on too long? Alternatively, the hospice might encourage them to “let go”…

The whole idea of “for-profit hospices” strikes me as a truly terrible idea—right up there with “for-profit prisons” (which have not worked out well). 

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Like so many other federal agencies, the National Institutes of Health (NIH) has struggled under the Bush Administration, and today, it needs to be revitalized. Not long ago, I wrote about what we can expect for the FDA when president-elect Obama comes to office; now I’d like to turn the NIH. But to understand the agency’s future, one needs to recognize its recent past.

The Bush Years: Starving the Beast

From 1998 to 2003, the NIH enjoyed a golden age. Over that span, the agency’s budget doubled to $ $27 billion, an increase that Harvard University president Drew Faust has called a "transformative force for biomedical research.” But since 2003, NIH funding has remained essentially flat and, when adjusted for inflation, it has actually declined.

This has caused concern within the medical research community While 10 percent of the agency’s budget funds in-house research, a whopping 85 percent supports biological and medical research at universities and medical centers. When the NIH has less money, it has less money to give—and more researchers on the cusp of biomedical breakthroughs miss out on the funding they need.

Last year, the Group of Concerned Universities and Research Institutions (GCURI)—an association of seven top-tier universities including Harvard, Duke, Johns Hopkins, and Brown—issued a report arguing that reduced funding for NIH means “slowing the pace of medical advances, risking the future health of Americans, discouraging [the country’s] best and brightest researchers, and threatening America's global leadership in biomedical research.”

Indeed, as the NIH budget has shrunk, researchers have had a harder time securing grants: according to GCURI’s report, the agency funded 32 percent of proposed research projects in 1999, but only 24 percent in 2007. Researchers who are awarded NIH grants also have to jump through more hoops than they did in the past. In 1999, 29 percent of grant proposals were approved upon first submission; in 2007, only 12 percent of projects were given the same first-time approval.  These days, 88 percent of researchers who end up with NIH funding do so after applying multiple times. According to GCURI “this trend represents a clog in the system that is causing researchers to abandon promising work, downsize labs, and spend more time searching for other financial support. Meanwhile,” the report continues, “Americans wait longer for cures.”

There’s no reason to think that the quality of grant proposals between 1999 and 2007 has dropped precipitously enough to warrant a stingier NIH. Good scientists are being left high and dry. The agency’s primary research grant—the so-called R01 grant—is generally regarded as the “gold standard” in science: when the government grants an R01 to a project, that research is officially legitimated as important, ground-breaking work. In fact, GCURI claims that “a scientist is not considered established and independent until he or she is awarded an R01, which…enable[s] scientists to hire staff and buy [the] equipment and materials necessary to conduct experiments.” Or, as Dr. Denis Guttridge, Associate Professor at The Ohio State University, puts it: “assistant professors cannot get going in their careers until they get their first R01.” Thus allowing federal grant money for medical research to shrink puts our country at risk of “los[ing] a generation of committed scientists” and the medical breakthroughs that they can provide.

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