Hat tip to Kevin M.D. for calling my attention to “The  Covert Rationing Blog,” where  Dr.  Rich offers a concise summary of the dilemma we   face as we move toward a consensus that healthcare is not a privilege,  but something that every human being should have. (One can call that a “right” or a “moral obligation that a  civilized   society has to provide  healthcare to everyone”).   The point Dr.  Rich is making is that once you decide everyone deserves health care, the  question is “how much care.” As he puts it:

  “Exactly how much healthcare are you entitled to  if you have a right to healthcare?  Do you have a right to certain  specified healthcare services, to a certain dollar amount of healthcare per  year or per lifetime, to  whatever healthcare it takes to achieve perfect health, or to some other limit or non-limit?

  “The question of limits (whether we should have  them or not, and what should  they be) has been a central theme of this blog and of DrRich’s book.  To reiterate the fundamental problem: 1) In  America we believe that it is wrong to limit healthcare in any way, that  everyone is entitled to the very best healthcare, that any bit of healthcare  that offers even a small potential of benefit should be provided, and that  death itself is merely a manifestation of insufficient research (or actionable incompetence,  or systematic  discrimination against the unwealthy, or corporate greed).  2) But  against that closely held belief, we must balance the unremitting law of  economics which tells us that there is simply not enough money in the known  universe to buy all the healthcare that might potentially offer some small  amount of benefit to every person.  Healthcare spending has to be limited,  or it will become a fiscal  black hole.”

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On November 3rd the Supreme Court will hear the case of Wyeth v. Levine, which has been called the “business case of the century”—and with good reason. In essence, Monday’s ruling will decide if patients have the right to sue pharmaceutical companies for personal injuries stemming from prescription drugs approved by the Food and Drug Administration (FDA). This is the big one, folks.

First, the details of the case: In the spring of 2000, Diana Levine of Vermont received treatment for migraines which consisted of the painkiller Demerol and Phenergan, an antihistamine manufactured by Wyeth Pharmaceuticals. Phenergan is typically injected directly into the muscle or dripped into the vein through steady doses (a procedure called an “IV drip”). When administering the drug, clinicians must be careful not to expose it to blood in the arteries; doing so causes “swift and irreversible gangrene,” to use an evocative phrase from a September New York Times article on Levine’s case.

Unfortunately, the physician assistant who attended to Levine administered Phenergan neither through muscular injection nor IV drip, but through a process called “IV push”—a direct intravenous shot in the arm. The assistant missed and hit an artery. Over the next few weeks, Levine, who was an avid guitarist, saw her right hand and forearm turn purple and then black—until both were finally amputated.

The court battle is over whether or not Wyeth Pharmaceuticals sufficiently warned against the dangers of IV push on its packaging for Phenergan—packaging that had been approved by the FDA. The drug’s labeling did warn that it was preferable to give Phenergan through IV drip, and warned that “inadvertent intra-arterial injection”—accidentally injecting the drug into an artery—could cause “gangrene requiring amputation.” But nowhere on the Phenergan label was there an express warning that the method of IV push is extremely risky for this very reason.   

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No doubt you’ve seen the ads. Barack Obama claims that John McCain plans to hollow out Medicare, arguably the most popular social program in America.

McCain says that just isn’t so.

The controversy began early this month when the Wall Street Journal reported that McCain plans major reductions in Medicare and Medicaid spending totaling $1.3 trillion over the text ten years. This will help pay for his health care plan. Douglas Holtz-Eakin, McCain’s senior policy adviser, told the Journal that “the savings would come from eliminating Medicare fraud and by reforming payment policies to lower the overall cost of care.”

Without question, there is money to be saved if Washington cracks down on Medicare and Medicaid fraud. But before reaping any savings, the government first would have to spend money to ferret out the fraudulent claims. And no one believes that Washington could recover anything close to $1.3 trillion. Meanwhile, “reforming payment policies” seems to suggest that McCain plans to pay doctors and hospitals less, at a time when many Medicare patients are having a hard time finding a primary care physicians—precisely because Medicare’s fees are already so low. This could reduce access to care.

Barack Obama quickly went on the attack with ads warning that McCain would take “Eight hundred and eighty-two billion from Medicare alone…requiring cuts in benefits, eligibility, or both.”

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At the end of last week, the Wall Street Journal published an editorial designed to terrify anyone who is afraid that a “single-payer” health care system would signal the end of democracy in America. The country is about to be taken over by the “left-wing,” the editorial warned, the same wild-eyed radicals who brought us the 1960s.  And what lies at the center of their master-plan? Medicare-for-all.

Since the piece relies so heavily on half-truths and innuendo—particularly with regard to healthcare—I feel obliged to comment.

The editorial, which is titled “A Liberal Supermajority,” begins by declaring that the election is a done deal: “if current polls hold, Barack Obama will win the White House on November 4 and Democrats will consolidate their Congressional majorities, probably with a filibuster-proof Senate or very close to it. Without the ability to filibuster, the Senate would become like the House, able to pass whatever the majority wants.”

“If current polls hold .  . .”   And, “if current polls” are accurate…

I have lived through enough presidential elections to know that the American electorate cannot be second-guessed.  Particularly in an election like this one, when highly charged issues such as loyalty to the nation, religion and race become part of the mix, one cannot assume that what a voter is willing to tell a stranger is necessarily the truth about how she will cast her ballot.

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Sometimes I agree with New York Times’ editorials. Sometimes I don’t. But I rarely learn much from them. To my mind, the problem with the form is that it encourages opining without evidence. So, I admit, I rarely turn to the editorials. .

But yesterday Buckeye Surgeon pricked my curiosity by referring to a recent New York Times editorial as a “masterpiece of naiveté and contempt.”

Such strong language suggested that the editorial might be entertaining. Thus, I went back and read what turned out to be a piece congratulating Medicare for having decided it “will no longer pay hospitals for the added cost of treating patients who acquire any of 10 ‘reasonably preventable’ conditions while hospitalized. Those include incompatible blood transfusions, severe bedsores, injuries from falls, poor blood sugar control, and infections after certain surgeries.”

This is what I mean about editorials: typically they are monologues that cry out for a good copy editor who asks sensible, logical questions.  The first query that springs to mind is this:  exactly what does “preventable” mean?  How is a “fall” preventable?

If Mr. Smith decides to get out of bed, begins shuffling toward the hallway, feels woozy, loses his balance and falls, how could the fall have been avoided?  Should a member of the staff be stationed not more than six feet from each patient, ready to race in and catch him if he teeters? Or should Mr. Smith have been tied to his bed?  (Thanks to HealthBeat reader Howard B. for his comment on hospital falls about a year ago.)

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This post was written by Niko Karvounis & Maggie Mahar

Consider this headline: “Health insurers reinvent themselves as money managers.”

The short version of the story, which appeared in the Los Angeles Times yesterday, is this:  “insurers are moving away from their traditional role of pooling health risks [and paying for health benefits]” and, instead, are beginning to move into money management as they offer to help consumers save for and pay for their own healthcare. If this strikes you as troubling—if, in other words, you think that health insurance should be about health care and not banking—then a closer look at  Michael Hiltzik’s well-researched piece will make your stomach churn. (Thanks to a Health Beat reader for calling our attention to what he called a “chilling” story.)

Health Beat has written about the health savings accounts (HSAs) that encourage consumers to sock away money away to pay for their own medical expenses in the past. To re-cap briefly: An HSA is like a 401k—you do not pay taxes on the dollars you put into the plan. There’s just one requirement: you can open a HSA only if you also buy a high-deductible insurance plan that typically offers minimal coverage, and a deductible of, say, $5,000. 

Because the premiums of high-deductible plans are so much lower than other health insurance products, they can be attractive to many low-income Americans—even if they do not have the extra cash to put away in an HSA (Remember: if you want an HSA, you must buy a high-deductible plan; but if you buy a high-deductible plan, you are not required to open a HSA.).

High-deductible plans are gaining traction in our health care system: America’s Health Insurance Plans report that, at the start of this year, 6.1 million Americans were covered by high-deductible plans—up from 3.2 million in 2006.

Why such fast growth? One big reason is that powerful health care stakeholders—namely, employers and health insurance companies—see the plans as a way to cut costs by shifting costs to the consumer.  As the Times points out, high-deductible plans offer “fewer overall benefits than traditional plans. They are designed to cover chiefly catastrophic medical expenses. Routine medical care becomes the responsibility of the consumer. Some of the plans exclude maternity benefits, preventive care and mental health services.”

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The conventional wisdom about skyrocketing healthcare costs tends to blame someone: patients who demand too much care; doctors who practice defensive medicine because they fear being sued; aging boomers, and finally, everyone’s favorite, “the insurance companies.”

In fact, none of the above is the driving force behind the nation’s spiraling health care bill, according to a brand new report from the Center for Studying Health System Change (HSC) titled “High and Rising Health Care Costs: Demystifying Health Care Spending.” (Many thanks to Robert Laszewski at Healthcare Policy and Marketplace Review for calling my attention to this report).

The culprit behind long-term health care inflation, the study reveals, is not a “who” but a what: “advancing medical technologies” combined with low productivity.  Yes, that’s right: while improved technology has boosted efficiency in other sectors of the economy, when it comes to healthcare, technological advances are associated with lower productivity.  There is no one group to be blamed for runaway healthcare inflation; the problem is systemic.

The HSC report is part of the Robert Wood Johnson Foundation’s “Synthesis Project” and it is indeed, synthetic. Paul Ginsburg, the report’s author, bases his study on an in-depth review of an “extensive literature that examines which drivers are most important in explaining increases in health spending over time.”  The conclusions “have been very consistent,” he observes. “Technological change (which in the world of medicine includes innovations in equipment, devices, drugs, tests, and surgical procedures) is the most important factor.”

But one thinks of ongoing technological advances as one of the great virtues of U.S. healthcare: how can we regret the high cost of that technology?

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At “Managed Care Matters”  (http://www.joepaduda.com/) Joe Paduda hosts a rich discussion for “Health Wonk Review,” focusing on the best of the blogosphere’s pre-election debate.

He begins with the question that I had raised on HealthBeat—and thatTom Brokaw later used to frame a health policy question during the presidential debate–Is Health Care a right or a moral obligation?”  (Do we think Brokaw readsHealthBeat?  Doubt it. Anyway, if you remember, I borrowed the idea fromShadow Fax, an emergency room doc who writes a blog titled “Movin Meat.”)

During the debate, presidential candidate McCain immediately rephrased the question from “moral responsibility” to “personal responsibility,” and then said,  “Yes, every individual is responsible for his care. This is very much in keeping with McCain’s “every man for himself” health care plan which emphasizes the individual and freedom of choice.

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Over at GoozNews, Merrill Goozner has written an excellent piece on Senator Hillary Clinton’s proposal to create a “Wellness Trust”—a fund that would consolidate the dollars that both public and private insurers now lay out for preventive health services, and then spend  that money in a way that gives us the biggest bang for our buck.

In his October 14 post, Goozner explains: “The new Wellness Trust would be run by 7-member board appointed by the president and approved by the Senate…in its first year of operation it would commission and then issue reports on the best way to supplement the existing health care workforce with certified ‘prevention health workers’; establish new reimbursement systems that would ‘align incentives’ with health promotion and disease prevention goals; and analyze current expenditures on prevention, which the bill estimates at 1 to 3 percent of health care costs or $20 billion to $60 billion.”

When Clinton talks about creating reimbursement systems that “align incentives” I believe that she, like the Medicare Payment Advisory Commission (MedPac),  is talking about the need to pay health care providers for the quality of their care—not the quantity. In other words, we want to pay for preventive care that actually leads to better health.  Some call it “paying for value,” and argue that this must be the centerpiece of health care reform.

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In discussing what’s wrong with health care in America, we often cite statistics—such as the fact that the U.S. spends 16 percent of its GDP on health care, yet has a life expectancy of 77.8 years, below the average of 78.6 years for OECD countries.

But health care is complex, and numbers can sometimes be too abstract to make a lasting impression on people who aren’t health care wonks. Sometimes what really connects isn’t data, but analogies that put health care in terms that everyone can understand. Of course, there are good analogies that illuminate and bad analogies that mislead, so you always have to be careful. Here are a few of the best and worst analogies that I’ve come across:

(1) The Titanic and Inequality. As The Health Care Blog (THCB) noted recently, it’s hard to come up with a more clichéd analogy than the Titanic. It’s really the poster child for much ballyhooed behemoths that collapse because they’re not nearly as state-of-the-art or invulnerable as people assume. But really, that’s a perfect encapsulation of our health care system. We spend $2.4 trillion on health care annually—the equivalent of bailing out Wall Street twice every year. As Shannon Brownlee of the New America Foundation has noted, as much as 30 percent of this bill is “spent on treatments, tests, and hospitalizations that did nothing to improve our health.” And we still have 47 million people without health insurance. This is not a ship that can keep afloat indefinitely.

But as Sarah Arnquist points out in her THCB post, our health care system isn’t akin to the Titanic just because it’s “a big, fancy expensive ship…[that’s] destined…[to] sink”—but also because survival of its passengers (or, in the case of health care, patient and citizens) is predicted by socioeconomic status. While a lot of people died on the Titanic, survival rates were much better for first class passengers (read: richer people) than for poorer folks: 97.2 percent of first class passengers survived the sinking, where as only 54.7 percent of third class passengers got out alive.

Similarly, in the U.S., your survival is predicted by your socioeconomic status. According to the National Center for Health Statistics, education level—which is strongly correlated with socioeconomic status—is “the most consistent predictor of the likelihood of death in any given year is level of education; persons ages 45-64 in the highest levels of education have death rates 2.5 times lower than those of persons in the lowest level.”

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