It’s no secret that the pharmaceutical industry trades in junk science. We’ve talked about how prescription drug companies distort research many times here on Health Beat, focusing on how companies fudge measures of drug effectiveness and generally control our knowledge of what works in medication. Big Pharma’s track record of shady science is a serious problem, especially considering the fact that recent discussions about creating a Comparative-Effectiveness Research Institute currently hold a place for prescription drug companies on the organization’s board.

The obvious problem is that, to the pharmaceutical industry, “research” is just a code-word for “smart-sounding marketing.” If you really want a sense of how deep this deception runs, consider the fact that the prescription drug industry relies on so-called “research” not just to shill its drugs, but also to argue that it has a vital role to play in shaping the doctor-patient relationship for the better.

This dubious claim comes in the June 2008 issue of PharmaVoice where Meaghan Onofrey from CommonHealth, a pharma marketing consulting firm, pens a piece arguing that coaching from the prescription drug industry can make sure that “physicians and patients speak the same language” so that “everyone wins.” According to Onofrey, “one case study illustrates [how marketers can help physicians improve their communication]: by videotaping primary-care physicians, who were struggling to assess migraine prevention candidacy with their migraine patients.” According to Onofrey, it turned out that the doctors were actually asking the wrong questions of their patients. In working with key opinion leaders and advocacy groups, a simple solution was formulated to address the issue. These same physicians were taught to ask a single question to help them more simply and clearly identify the patients’ candidacy for migraine prevention.”

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In 1970,  a Fortune magazine cover story warned the nation: “Much of U.S. medical care, particularly the everyday business of  preventing and treating routine illnesses , is inferior in quality, wastefully dispensed, and inequitably financed.” That year, a Fortune editorial declared: “The time has come for radical change…The management of medical care is too important to leave to doctors who are, after all, not managers to begin with.”

This was the beginning of the revolution Paul Starr described in his Pulitzer-prize -winning 1982 book,  The Social Transformation of American Medicine.  In his final chapter, “The Coming of the Corporation,” Starr expressed his concern that “those who talked about ‘health care planning’ in the 1970s now talk about ‘health care marketing. Everywhere one sees the growth of a kind of marketing mentality in health care. And, indeed, business school graduates are displacing graduates of public health schools, hospital administrators and even doctors in the top echelons of medical care organizations.

“The organizational culture of medicine used to be dominated by the ideals of professionalism and voluntarism which softened the underlying acquisitive activity,” Starr wrote. “The restraints exercised by those ideals now grows weaker. The ‘health center’ of one era is the  ‘profit center’ of the next.”
In this brave new world of the 1980s, corporate executives would become both the  wealthiest and the most powerful actors on the new cultural stage.  Hospital CEOs would haul home salaries that made neurosurgeons look like pikers.  In health care, as in other industries, CEOs, not physicians, make the decisions, and their goal, Starr suggested, would no longer be better health, but rather, “the rate of return on investments.”

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The Kaiser Daily Health Policy Report below announces that the Chairs of the Senate Finance and Senate Budget Committees have introduced a bill to create a Comparative Effectiveness Institute.

The question: Would its decisions guide Medicare’s decisions about what it covers?  Clearly Congressional Budget Office Director Peter Orszag thinks the Institute would have some real power: He estimates it “could save up to $700 billion annually in health care spending by identifying treatments that do not produce the best medical outcomes.”

That’s the $1 out of $3 health care dollars that we now waste on unnecessary, unproven, ineffective and often over-priced treatments.

Of course, we wouldn’t save anything close to that amount at the beginning. It will take years to wring the waste out of the system. But putting U.S. healthcare on an evidence-based footing would be a giant step toward the national health reform we need.

I am also encouraged by the fact that the 18 members of the Institute’s panel would be appointed by the Comptroller General. The Comptroller General appoints the members of the Medicare Payment Advisory Commission (MedPac), and they have been producing extremely intelligent reports. They are also widely perceived as apolitical.

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Last month I wrote a post highlighting a truly boneheaded development in the Department of Defense (DoD): the introduction of AHLTA, a new system of electronic medical records for the military. Usually I’m a big fan of electronic medical records (EMRs), but not in this case  AHLTA is an entirely new system built by military contractors and funded by taxpayer dollars. Its mere existence is wasteful, because the military has long had a high-quality health care IT system in place called VistA, the Veteran Administration’s (VA) EMR system. And VistA  could have served as a very efficient foundation for modernize military health records. 

As I’ve mentioned in the past, VistA has quite a lot going for it: the VA has improved productivity by 6 percent a year since it was implemented in VA hospitals nation-wide; VistA has helped the VA cut its health care costs by 32 percent since 1996; and the VistA computerized prescription system is incredibly accurate, correctly matching patients and medication 99.997 percent of the time. It makes little sense to ignore this homegrown asset when setting out to build a broader DoD EMR system. Worse still, AHLTA can’t even communicate with VistA, adding a new layer of dysfunction to the military’s IT development.

This is all incredibly foolish, but maybe the real kicker is that AHLTA is proving a total failure. Not only is it a waste from an IT development stand-point, but it’s also proven to be a hindrance to the very military clinicians whom it’s supposed to be helping.

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Over at Kevin M.D.’s excellent website, The Happy Hospitalist recently posted a “Reader’s Take” on Medicare that sparked  a fierce debate.

The Happy Hospitalist began by pointing out, rightly, that Medicare is approaching a financial crisis:  “On March 25, 2008 the Boards of Trustees released their Annual Report of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. In this 43rd edition, the Trustees note [Medicare is] a government program covering just over 44 million people at an expense of $425 billion dollars during 2007. That equates to approximately $10,000 per beneficiary.

“Ten thousand bucks. A cost accelerating at an unsustainable rate”

This is entirely true.  If we continue in our profligate ways, Medicare will break the bank. But then Happy Hospitalist explained his solution:

“The appropriate course of action should be a radically new approach to the Medicare entitlement program…A restructuring of the program towards a transparent means based qualification system is necessary. Having Uncle Sam pay for an elective cataract surgery so grandma can go on an African safari is inexcusable in a time of financial collapse.”

Often I agree with The Happy Hospitalist. But on this point, I cannot.

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In a post originally published on The Health Care Blog  and reprinted on Bob Laszewski’s Health Care Policy and Marketplace Review, health care analyst Brian Klepper asks: “Is Meaningful Health Care (Or Any Other Kind Of) Reform Possible?”

His answer: “I’d be surprised. Delighted! But surprised.”

I decided to answer him.

Klepper believes that the lobbyists are just too strong. Always incisive, he pulls no punches: “In a policy-making environment that is so clearly and openly influenced by money,” it’s just not likely that “Congress will be able to achieve health care reforms that are in the public interest.”

I disagree. I believe economic pressures are pushing us toward a political turning point. (If you want to understand what is happening in history or in politics, follow the money.) The Bush administration has been thoroughly discredited. Americans are ready for change. Healthcare reform will not happen tomorrow; it will require a bare-knuckled political fight. But it will happen, and this is why: Although lobbyists are powerful, so are voters. And they realize that we are approaching a flashpoint.

You’ll find the rest of the post here.

To comment, come back here.

Reel back to 1965, the year Medicare and Medicaid legislation was passed. That year Congress gave the “Joint Commission,” a professional accreditation organization established in 1951, the unique authority to inspect hospitals and determine whether they meet the patient health and safety standards required to treat Medicare patients.

And who do you suppose pays the Joint Commission?

The hospitals that are being inspected. “Today, the Joint Commission collects $113 million in annual revenue, mainly from the fees it charges hospitals for telling them whether they comply with federal regulations,” observes Lisa Venn, J.D. M.A., writing on Advocate Alliance. 

Venn, who is the Manager of Compliance at a large teaching hospital, explains that “Deeming authority means that if Joint Commission gives its seal of approval to a hospital, CMS is satisfied that the hospital is following federal regulations. In other words, hospitals enrolling in the accreditation program only have to please one master. And that master is really nice, accrediting 99% of all hospitals it surveys.”

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It’s always worth exploring how health care works in other countries, if for no other reason than that models in other countries give us the chance to see how some of the approaches discussed by American reformers might pan out. What do the experiences of Germany and Netherlands tell us about the possibility of a better mixed public-private system in the United States? How is China’s health care system a cautionary tale of market forces gone wild? The answer to these questions can add to—or detract from—the appeal of certain health care strategies in the U.S.

It’s hard to imagine a country that could provide a more valuable example than Singapore. The Southeast Asian city-state is widely regarded as a health care superstar, especially when compared to the United States. Life expectancy at birth in the U.S. is 78 years; in Singapore, it’s 82 years. The Singaporean infant mortality rate is a mere 2.3 deaths per 1,000 live births, versus 6.4 in the U.S. As some have noted, these trends persist despite the fact that the U.S. has far more caregivers: 2.6 physicians per 1,000 people, compared with 1.4 physicians in Singapore. The United States has 9.4 nurses per 1,000 people; Singapore, just 4.2. Last—but certainly not least—is the issue of spending: the U.S. spends almost 16 percent of its GDP on health care, while Singapore spends a mere 3.7 percent. 

For reformers eager to cite examples proving that their health care ideals are a formula for success, Singapore offers a powerful case study. Its population is healthy, its system isn’t overloaded by medical professionals, and health care spending doesn’t gobble up a huge chunk of its economy. 

So how does Singapore do it?

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Did you know that Japan has found an ingenious way to “create” money that can be used to care for the elderly?  Bernard Lietaer, author of Access to Human Wealth: Money beyond Greed and Scarcity (Access Books, 2003) describes the system in this interview with Ravi Dykema, publisher and editor of Nexus, a leading Holistic journal.

Lietaer begins with the basics, by explaining what money is: “I define money, or currency, as an agreement within a community to use something as a medium of exchange. It’s therefore not a thing, it’s only an agreement – like a marriage, like a business deal…And most of the time, it’s done unconsciously. Nobody’s polled about whether you want to use dollars. We’re living in this money world like fish in water, taking it completely for granted.”

Lietaer, who co-designed and implemented the convergence mechanism to the single European currency system (the Euro), and served as president of the Electronic Payment System in his native Belgium, doesn’t take currencies for granted. He knows that a dollar is simply a piece of paper (which is no longer backed by gold).  It has value because we have agreed that it has value.

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In the July 28th issue of The New Yorker you’ll find an entertaining story by David Samuels that explores the economy of pot in California, where medical marijuana has been legal since 1996. Focusing on the supply and distribution chains that help to get pot in the hands of patients, Samuels weaves a colorful yarn, but one that focuses heavily—and somewhat derisively—on the personalities involved. Given the author’s emphasis on the stereotypical stonerdom surrounding legalization, the casual reader may come away thinking that medical marijuana is just another hippie cause, a 60s-style cultural crusade rather than a question of health care. But that’s not the case. 

Aging Hippies

Samuels’ account of the medical marijuana industry boasts quite a cast. There’s “Captain Blue,” a middle-aged grower with “black and greasy hair” and ill-fitting tee-shirts that “expose his round belly.” He sells weed to dispensaries that supply medicinal marijuana. Then there’s “Lily,” who transports ganja “from Northern California to Blue’s apartment” in the trunk of her car, and a woman named “Cindy 99” who runs a dispensary and who looks like an “adolescent boy’s fantasy of his best friend’s hot older sister.” Finally let’s not forget “Dr. Dean,” the free-wheeling M.D. who regularly prescribes marijuana thanks to a watershed night at his friends’ where he was introduced to marijuana via spiked lollipops and brownies. “It was like Amsterdam,” he dreamily tells Samuels.

If these sound like the characters from a teen stoner movie, that’s certainly the way that they’re represented by Samuels. With such an emphasis on the weed enthusiasts, it’s perhaps unsurprising that the author’s big conclusion about medical marijuana is that it’s just another way to keep the pseudo-subversive indulgences of the 1960s alive. “The legalization of medical marijuana has allowed for the illusion that farming pot can provide opportunities for travel and cool art projects and personal growth,” says Samuels. He then concludes that for aging hippies, “growing ganja lets you feel that you’re still living on the edge,” particularly if you’re a washed-up, wannabe political radical.   

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