Today, as the first in an ongoing series of updates on what’s new in international health care, I want to take a look at recent reforms in Germany. As a whole, we Americans pay precious little attention to what’s going on in other countries unless the news involves war or David Beckham. I’m hoping to buck this trend a little.

The big story in German health care is Chancellor Angela Merkel’s late 2006 reform that resulted in series of changes that, for the most part, were implemented in April of last year. Below, a look at these reforms; but first a little political background: Merkel heads up a "grand coalition" government, i.e. one where the largest political parties govern in collaboration due to inconclusive election results (a relatively common occurrence in parliamentary systems). In other words, social democrats and conservatives are in a constant tug-of-war. The new plan reflects this fact, juggling solidarity and competition in equal parts. And while this might sound like a good balance, virtually no one is satisfied with the compromise.

On to the big changes:

Mandatory Health Insurance: Many folks think that European health care means, by definition, universal public coverage. Not so. Germany has a public/private system, and before the April 2007 reform, public coverage was only compulsory for those within a certain income range (roughly speaking, working and middle class citizens). Higher-income and self-employed Germans, along with public servants, could opt-out of SHI by purchasing private insurance. They could also forgo insurance all together.

Due to this set-up, until recently some 200,000 Germans were uninsured—about 0.2 percent of the population. As of April ’07, all Germans must purchase health insurance. In the past, private insurers (who traditionally offer plans with many bells and whistles) had the right to refuse coverage for high-risk individuals. Now, they must take all comers. In this way, the new German plan is like Hillary Clinton’s proposal for health care reform: insurers can no longer shun the sick but everyone must sign up—citizens cannot wait  until they are sick to enroll.

Continue reading →

Two seasoned political strategists, Paul Begala, and Stan Greenberg, spoke at “Health Action 2008,” a conference that Families USA sponsored in Washington last week.  There, they argued that the U.S. may be on the threshold of what Begala, a political contributor on CNN’s “The Situation Room,” called “a totally new deal.”  Greenberg, chairman and CEO of Greenberg, Quinlan Rosner, went a little further: “It is very possible that the whole conservative complex crashes.”

In an interview later that afternoon, Greenberg explained what he meant: “I think this election is going to mark an extraordinary defeat for conservatives.” Greenberg isn’t talking about the number of Congressional seats that the conservatives may lose: he is not forecasting a sweep for Democrats that equals the LBJ landslide. Instead, he’s predicting something more fundamental: that the right wing of the Republican party will be shattered. “There may be a fragmentation on the conservative side that changes what’s possible after the election.”

For many who came of age in the 1980s and the 1990s, this must seem unimaginable. For the past 28 years, the U.S. government has been held captive by the conservatives. Ronald Reagan sowed the seeds and George W. Bush harvested the fruit of a political movement bent on deregulation and smaller government while consolidating and preserving the wealth of the country’s richest citizens.

At the beginning of Bill Clinton’s first term, it seemed that the nation might be ready for deep changes, in large part because we had entered a recession that was threatening not just blue collar but white collar workers.  Middle-class and upper-middle class employees were afraid that they were going to lose not only their jobs, but their health insurance.  But as that recession eased, Bill Clinton’s first major initiative went down in flames.  A health care reform plan that would have signaled the beginning of progressive economic reform failed, in  part because Americans were no longer as anxious as they had been when Clinton captured the White House.  (Ezra Klein recently did a superb job of putting the death of the Clinton healthcare plan in context, explaining how a combination of “bad timing, political misjudgment and human error” conspired to kill what had been a “courageous effort” to pass health reform.)

But now, Begala and Greenberg say, the time is ripe for radical reform. They make their argument based both on the fact that the conservatives are in disarray and on what Americans now say when they talk to pollsters about healthcare reform.  In September, 62 percent of those polled said that “rising health care costs are a very serious problem in the economy”—up from 50 percent a year earlier. And, as the recession deepens, that number is likely to climb.

Continue reading →

Tomorrow (Tuesday) night, at 8:30, HBO will air a documentary titled “Baghdad Hospital: Inside the Red Zone.” The film offers an inside look at Al-Yarmouk hospital in Baghdad, as seen through the eyes of a doctor. Once an ordinary hospital, Al-Yarmouk has been transformed by insurgency and sectarian strife into a “field hospital in a civil war.” It is the epicenter of hope and despair for thousands of wounded Baghdad civilians and their families. 

Filming inside Al-Yarmouk’s emergency room was too dangerous for an American crew to attempt.  Only an Iraqi ER doctor could do the job.  This is his story.

With the film’s debut on HBO, Dr. Omer Salih Mahdi reveals his identity to the world for the first time. Until now, he has remained anonymous to protect himself and his family. Dr. Mahdi’s face is not revealed in the film and an actor has recorded his words.

Given permission by hospital authorities to use a hand-held camera inside the emergency room, Dr. Mahdi reveals some of the horrific injuries sustained by Iraqi men, women and children, and exposes the substandard conditions, low morale and danger that its doctors and nurses endure on a daily basis.

Like the American GIs in HBO’s acclaimed 2006 documentary "Baghdad ER," many of the people hospitalized in this film are victims of gunfire or improvised explosive devices (IEDs). Here, however, the victims are Iraqi civilians caught in the crossfire of the ongoing sectarian violence between Iraqi Shiites and Sunni insurgents.

Life inside the hospital is dangerous: Gunshots frequently ring out inside the ER, and insurgent militia fighters often storm its doors. Doctors are targets, partly because, as one puts it, "We’ll treat anyone: Shiite, Sunni, whoever." But it’s much more treacherous for those working outside. Ambulances are sometimes shot at and ambulance workers have been killed, either mistakenly by Americans or deliberately by extremists.

Continue reading →

A few days ago, Merrill Goozner at Gooznews posted a great commentary on a recent New York Times article that reveled in the so-called “revolution in medical prognostication.”

This time, the amazing innovation is a DNA test that helps to predict mens’ risk of getting prostate cancer at the low, low price of $300. But as the article points out, this test “cannot predict which men will get aggressive cancers” and thus “could lead to more screening and unnecessary surgery and complications.” In other words, it gauges the risk—not the inevitability, and not the severity—of prostate cancer. Defenders of the test say that if all goes according to plan, men “may want to get the new genetic test when they are young” so that they can get a jump on prostate cancer treatment.

But here’s the problem: prostate cancer treatment is, more often than not, less useful than you might think. Merrill points out that it’s “already overdiagnosed and overtreated with horrendous side effects for thousands of late middle-aged men.” Here at Health Beat, Maggie has also noted that while the risk of prostate cancer is often hyped, almost every authoritative medical body on the matter agrees that the benefits of screening and treatment of early-stage prostate cancer are highly uncertain. There is no evidence that early treatment prolongs life by a single day.  We excel at finding out if there might be the need to do something, but we know very little about the impact of what it is we actually do.

Continue reading →

Today I’m in Washington, attending Health Action 2008. Families USA organized the event and invited me to come down and blog about it. Yesterday morning we heard Congresswoman Nancy Pelosi lay out her views on the health care issues facing Congress and I was both surprised and impressed by the strength of her speech.

Pelosi stressed equality: “We must fund bio-medical research,” she declared, “and the benefits must belong to every single American.”  She went on to point out that “in order to have this research available to all, we have to have a common electronic record—bringing everyone into the loop.” In other words, a single electronic medical record could provide the database everyone needs to see what works and doesn’t.

To be truly valuable, that database must be as broad as it is deep. As Pelosi put it, “the healthcare of the most privileged person in American benefits if everyone has health care, and if we have a common electronic record.”  (Pelosi also emphasized that this record must respect the privacy of everyone involved, keeping medical information about individuals confidential.)

She went on to say that while “bringing everyone into the loop, we must eliminate the disparities [in the quality of care that different groups in this country receive], not just from a sense of fairness—which would be justification enough alone—but in terms of insuring better health for the nation.”

Continue reading →

Yesterday I was watching television and was bombarded with the following infomercial for a dietary supplement called Lipozene:

No doubt your bull-you-know-what detectors are going haywire already, as well they should. But before you write off Lipozene as a joke, consider this: there’s nothing that the manufacturer of Lipozene—the Obesity Research Institute (ORI)—does that prescription drug companies don’t do every day. In fact, by analyzing Lipozene’s marketing, we can get a clear picture of the fundamental building blocks of Big Pharma’s business practices.

The active ingredient in Lipozene is glucomannan, a complex carbohydrate found in the konjac plant. Since glucomannan is an insoluble fiber, it absorbs water to form a thick gel that coats the stomach, making you feel full—thus reducing your eating.

For all that ORI’s advertisement irritates, it does contain a kernel of truth: the appetite-suppressing effects of glucomannan have been shown to help weight loss. A 1984 study showed that 1 gram of glucomannan before meals helped obese people lose an average of 5.5 lbs over eight weeks. Of course, this specific number is never cited in the Lipozene materials, with advertisements instead touting the fact that 78 percent of every pound loss was pure body fat and that “people were not asked to change their daily lives.”

Continue reading →

As part of a continuing series on health care spending, last week I looked at what share of our health care dollars goes to pay for physician’s fees and clinical services. As the pie chart below shows, 22 percent of the $2.1 trillion that we spent  on  health care last year went directly to doctors. That’s up from 19.4 percent in 1960.

Most of the jump came in the 1960s and 1970s—though physician incomes continued to grow in the 1980s, rising 30 percent from 1984 to 1989, or about twice as fast as the average increase for other full-time workers.

I promised that this week I would publish a Part II to last week’s post and look at how much doctors are paid in other countries, how hard they work compared to doctors in the U.S., and how patients are faring as physicians’ incomes continue to outstrip both inflation and wages nationwide.  Finally, I said I would discuss whether we are spending too much on physicians services—and how we might change the way we pay them.

But first, let me very quickly re-cap the background to this story. In recent years, doctors’ fees have come under pressure. In the 1990s, managed care companies set out to pare costs by questioning virtually every bill that doctors sent them and in recent years Medicare has been trying to keep a lid on spending by refusing to raise most doctors’ fees.  Many private insurers have been following Medicare’s lead. Meanwhile, the cost of running a practice has been climbing, making it hard for some doctors (particularly primary care physicians) to stay afloat financially.

Nevertheless, by increasing the number of patients they see and the number of procedures they perform, many doctors have been able to boost their incomes.  More entrepreneurial doctors also have been making investments in surgical centers—creating a second income stream.  Thus, the overall amount that we spend on physicians’ services continues to rise: up 6.2 percent in 2000, up 8.3 percent in 2003, up 7.3 percent in 2004, up 7.4 percent in 2005, and gaining another 5.9 percent in 2006.

But not all physicians are prospering. The charts I ran last week show pediatricians, family doctors and others who practice what some call “cognitive medicine” (talking to and listening to the patient ) making as little as $115,000 a year while specialists who perform the most aggressive procedures haul home $800,000.

Continue reading →

As a nation, we are spending well over two trillion a year on health care. What exactly are we paying for? In a December 6 post, I asked how much of that $2 trillion goes to private insurers in order to cover “administration”– which includes advertising, marketing, underwriting, lobbying, multi-million dollar executive salaries, and profits for  shareholders.

As the pie chart below shows, it turns out that in 2006, after taking in premiums and  paying out reimbursements,  private insurers  kept  close to $95 billion—or about 4.5 percent of the $2.1 trillion we spent on care—to fund everything from advertising to CEO bonuses.  Meanwhile, private insurers paid roughly one-third of the nation’s health care bills.  (By contrast, the government picked up nearly half of  the $2.1 trillion tab through programs like Medicare, Medicaid, SCHIP while spending only $525 billion —or about 2.5 percent of the $2.1 trillion—on administration.)

Ninety five billion dollars represents the difference between what private insurers received in premiums and what they paid out in reimbursements, and it’s a big number. But as I commented in my December post, even if we eliminated the private insurance industry’s role in our health care system, the $95 billion saved would be wiped out by just one year of health care inflation.

Inflation: that is the elephant in the middle of the room. In 2006, total spending on health care climbed by 6.7 percent, or $132 billion, to $2.1 trillion. In 2007, economists expect an even bigger jump.The pie just keeps on growing, year after year, far faster than the average workers’ wages: up 8.6 percent in 2003, up 6.9 percent in 2004, up 6.5 percent in 2005, up 6.7 percent in 2006…And there’s no end in sight.

Continue reading →

Okay, not really—but still, unsettling news from yesterday’s NEJM. According to a report from professors at Oregon Health and Science University, Kent State University, and Harvard, negative studies of anti-depressant publications are much less likely to be published in research journals than positive ones.

The authors compared 74 FDA studies for 12 antidepressant agents, which involved a total of 12,564 patients, to those published in medical journals—the goal being to see which studies made it from the insider circuit to the printed page, and how those that did make the jump were altered for publication.

They found that among the FDA-registered studies, “studies viewed by the FDA as having negative or questionable results were . .  . either not published (22 studies) or published in a way that . . . conveyed a positive outcome (11 studies).” In other words, bad news didn’t make it to the journals—or it was spun to sounds like good news.

Indeed, according to the study, if a reader were to judge the medications solely based on the published studies, they would think that “94 percent of the trials conducted were positive.” But in fact, “the FDA analysis showed that 51 percent were positive.”

Obviously, medical journals are publishing research that over-sells the effectiveness of anti-depressants. But why? The answer is exactly what you think: a big, fat conflict of interest. Medical journals have a lot to gain by giving designer drugs the benefit of the doubt—even if it’s undeserved.

In a well-known 2006 BMJ study, professors from York University and the University of Medicine and Dentistry in New Jersey, analyzed the messy world of “commercial bias in medical journals.” The risk here is self-explanatory: sometimes the business of medicine encroaches on medical research, especially when it comes to prescription drugs.

But despite the ubiquitous for-profit interests circling around medical journals, the BMJ study found that only nine of 30 peer-reviewed general and internal medical journals “had an explicit policy for dealing with editors’ financial conflicts of interest.” The rest pretty much just wing it—a dangerous strategy when their publications are so economically vulnerable.

Continue reading →

You’ve probably heard of retail health clinics (RHCs), “drive-thru” medical centers that offer relatively simple and cheap medical services in stores like CVS and Wal-Mart. They’re all the rage nowadays, with their number doubling over 2007, from 300 to about 600 nationwide. At the end of this year, their numbers are expected to triple, hitting 1,800.

The RHC explosion has caused concern in some circles.  Primary care physicians are particularly worried that the clinics represent a threat to their practice and could disrupt continuity of care. Other concerns come from people like yours truly, who worry that the old formula of profit motive plus market opportunity could lead to a feeding frenzy that would compromise the quality of care.

Retail clinics are so new that these concerns can sometimes seem premature; but judging by one 2007 document that I recently came across, my worries are well founded. Even the people trying to grow the RHC market see these health care problems coming—but they view them as business opportunities.

What people often forget about for-profit initiatives like retail clinics is that they’re bent on growth. They may start small, but they don’t want to stay small. The business plan goes beyond today’s headlines. Investors want projections; they want a roadmap to the future; they want to know that challenges have been accounted for. That means that RHCs aren’t just concerned with the here and now, but also how the market can sustain itself in the future. And according to “Business Intelligence to Achieve the Goals of Retail-based Clinics,” a briefing from the Business Intelligence Network authored by Scott Wanless, the only way to do that is to look well beyond the current RHC formula.

Continue reading →