Health Wonk Review, a compendium of some of the best health care blog posts of the past two weeks, is up at The Health Care Blog. This week’s host, Brian Klepper, has done a superb job of picking out 20 stellar posts. Here are just a few that caught my eye:

“Over at Health Populi,” Klepper writes, “the ever-reliable (and charming) Jane Sarasohn-Kahn reviews new health consumerism data from the Employee Benefits Research Institute/Commonwealth Fund. Enrollment in Consumer Directed Health Plans (CDHPs) is slight but growing, from a mere 1 percent of people with private coverage in 2006, to 2 percent in 2007…Contrary to the hopes and rants of the ideologues on the right, it turns out that the enrollees in these plans tend not to be born-again uninsureds, but the healthy and wealthy.”

“On the Health 2.0 Blog, the always-entertaining veteran health care commentator and Quality Grand Poo-Bah Michael Millenson takes us on a ride that forces some introspection. In the extremely complex world of evolving health information on the Web, do we health observers drink our own Kool-Aid? ‘Are we open to objective data about what we do, or do we prefer to publicize only affirming anecdotes?’ It’s an uncomfortably reasonable question, and a fair warning.”

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A HealthBeat reader sent me an e-mail about a PBS documentary that is airing tonight.  It’s called “Unnatural Causes” and it describes the major cause of sickness in America. I haven’t seen it, but it sounds interesting.  The documentary first aired last Thursday and will be aired again nationally today (April 3) and the next two consecutive Thursdays at 10PM (local dates and times may vary).

Over the weekend, I read a piece by Brian Klepper on “What Worksite and Retail Clinics Mean for the Primary Care Crisis” over at Robert Laszewski’s excellent blog, Health Care Policy and Marketplace Review.

Klepper is a health care analyst based in Atlantic Beach, Florida who often writes for The Health Care Blog. I met him at a healthcare conference in Washington D.C. a few months ago and found his ideas very interesting—although we don’t agree on everything, as you will see.

Intrigued by Brian’s post, I decided to write a comment. Bob Laszewski then got in touch with me and suggested that he turn my comment into a full-fledged post, and asked Brian to reply.

Below, Brian’s original post, my reply and a link to his response.

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It’s a well-known fact that China is the most populous nation in the world. But here’s a question for you: how the heck does a country—especially one in the midst of breakneck economic development—provide health care to 1.3 billion people? The answer is “not all that well,” thanks to a decades long bout of capitalism-gone-wild that’s reduced Chinese health care to a shadow of its former self.

For most of the 20th century, China was a communist society. But in 1978 the government introduced market-based economic reforms aimed at liberalizing the economy. These changes included the creation of open markets for farmers to sell their crops, the creation of pricing systems, bank reforms, and an embrace of foreign direct investment. 

These reforms, along with many others, have produced some spectacular economic results; but by the 1980s they also demolished China’s traditional health care system, which had been in place for some thirty years.

The now-defunct cooperative medical system (CMS) was a three-tiered framework centered on rural communities, the population of which has long constituted the majority of Chinese. According to Gregory Chow, a noted Princeton economist and China expert, the first-tier of the CMS consisted of “part-time [and salaried] barefoot doctors in health clinics [who] provided preventive and primary care.” Despite being farmers who received only minimal medical training, these barefoot doctors were the Chinese equivalent of primary care physicians—the point of first contact for patients with medical concerns.

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Most people who read this blog understand how drug companies use their reps to try to influence the kinds of medications that physicians prescribe. The question is: do they really have an effect on how most doctors practice medicine? 

Below, an insider’s look at how drug reps operate from the Carlat Psychiatry Blog. A former Eli Lilly rep may sum it all up when he says: “Gift giving is the key. You are programmed as a human to reciprocate . . . As a matter of fact, the smaller the gift, the greater the sense of obligation.”

Thursday, March 27, 2008 : A Drug Rep Tells All

Shahram Ahari, former Eli Lilly drug rep, recently spoke to the Tufts Progressive Medical Students Organization. It was a fascinating talk, because Ahari told us about how he and his colleagues used every trick of salesmanship in the book to increase prescriptions of Prozac and Zyprexa and therefore to maximize their bonuses.

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It is time, I think, to face the realpolitik of health care reform. That means asking a question few reformers dare to discuss:  How will we win the Congressional votes needed to pass serious health care reform?

The American Prospect’s Ezra Klein put this question on the table at the “Take Back America” conference last week.  A pragmatic progressive (in the best sense), Klein pulled no punches:  “There are so many people in this town [D.C.] who do such smart policy thinking,” he observed. But “what we don’t give enough thought to is the politics of reform. This is a political problem. Until we have the votes in the Senate, we can’t get anything done.”

Without the votes, Klein told reformers, “you don’t have a plan; you have a position.”

Some assume that, if we elect a progressive president, he will “put the votes together” to achieve reform. But the fact is that even an optimistic, charismatic JFK wasn’t able to persuade Congress to unite behind healthcare for the elderly in the early 1960s—a time when seniors were the poorest group in America. It was only after Kennedy was assassinated that a wily LBJ (who had grown up in Congress and knew where all of the bodies were buried on the Hill) was able to leverage a martyred president’s last wishes to help pass Medicare in 1965. The fact that LBJ had won by a landslide sealed the deal.

This time around, nailing the votes that would secure something like “Medicare for Everyone Who Wants It” will be much tougher. As I noted in my first post in this series, “Obstacles to Health Care Reform,” the lobbyists representing the for-profit health care industry enjoy enormous power. The money at stake in the health care industry has grown exponentially since 1965. And thanks to generous campaign contributions, the industry’s lobbyists wield great influence, even among liberal politicians.

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Finally, the National Association of Government Employees (SEIU) has responded to the story I posted last week reporting that its affiliate, the International Association of EMTS and Paramedics (IAEP/SEIU), has been sending out letters to doctors, endorsing Pfizer’s blockbuster drug Lipitor.

Lipitor, like other statins, has been getting some bad publicity of late (see “The Cholesterol Con”) and apparently someone decided Lipitor needed a boost.

Today, I learned that someone who signed himself “anonymous” had replied to my post on Health Care Renewal, where Dr. Roy Poses, the blog’s editor, had cross-posted my SEIU piece. Here’s the response:

SEIU Does Not Endorse Lipitor or Any Other Product (Full disclosure—I work for SEIU.) If Ms. Mahar had bothered to contact us, she would have learned that as a matter of policy, SEIU does not endorse products. Official Statement from SEIU: Recently, a letter appearing to endorse a well-known pharmaceutical was circulated by the International Association of EMTS and Paramedics, an affiliate of the National Association of Government Employees (IAEP/SEIU).SEIU does not endorse products. The letter was generated by a Local Union staff member unfamiliar with SEIU’s policy against any product endorsement. Upon learning of the letter, the Local disavowed a relationship with the product in keeping with the union’s policy.

The 1.9 million member Service Employees International
Union is united by the belief in the dignity and worth of workers and
the services they provide and dedicated to improving the lives of
workers and their families and creating a more just and humane society.
SEIU members are winning better wages, health care, and more secure
jobs for our communities, while uniting their strength with their
counterparts around the world to help ensure that workers, not just
corporations and CEOs, benefit from today’s global economy.

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Reforming U.S. healthcare will be difficult,  in part because our current system is riddled with conflict of interest. Virtually any health care reformer will tell you that if we are going to have a high quality, sustainable health care system, we will need an independent health care agency that oversees quality by making sure that decision are based on the best medical science available. “Independent” means that this agency must somehow be insulated from both special interests and politics.

If this sounds Utopian, it isn’t. In my first post, I suggested that we might find a model for just such an agency in the U.K.’s National Institute for Health and Clinical Excellence (NICE). To be sure, we would not want to emulate NICE in all respects. Operating on a very tight budget, NICE puts a major emphasis on the cost-effectiveness of the treatments it approves. In the U.S., we could  vastly improve the quality of our care—and save billions—if we just looked at the “comparative-effectiveness” of services and products, without worrying about how many additional years of life $100,000 would buy.

What is remarkable about NICE is its independence. And this is what we should take as a pattern for what is possible.  Founded in 1999, the institute operates with almost no interference from either private sector lobbyists or government.

Sitting at the very center of the U.K.’s health care system, NICE is charged with watching over the quality of care in the U.K. by drawing up “best practice guidelines” for physicians, while also reviewing new and existing medicines, technologies and treatments. The National Health Service of England is legally obliged to provide funding for drugs and procedures recommended by NICE’s independent technology appraisal board. So implicitly, NICE also is deciding what the national health system will cover.

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Today, AlterNet published a provocative story by Mark Weisbrot , co-director and co-founder of the Center for Economic and Policy Research, about the emerging battle between Big Pharma and the developing world.

Some large pharmaceutical companies are “up in arms,” Weisbrot notes, because “developing countries are importing less expensive generic versions of drugs for which these companies hold a patent monopoly.”

But “the procedure is perfectly legal, even under the World Trade Organization’s pro-pharmaceutical-monopoly rules. The only question is whether these huge corporations –who used their political muscle in Washington to prevent our government from lowering the price of Medicare prescription drugs—will intimidate governments that are trying to provide essential medicines to their citizens.”

Weisbrot points to Thailand as “the latest target of this bullying last winter when it issued ‘compulsory licenses’ for three drugs. Two were anti-AIDS drugs (efavirenz and lopinavir/ritonavir) and the third is used to treat patients with cardio-vascular disease (clopidogrel). A compulsory license allows for the production or import of a generic version of a patented drug, without the permission of the patent holder. It is completely legal, and in fact the United States has used compulsory licenses many times.

“But the U.S. government has sided with the big pharmaceutical companies and put Thailand on a special ‘Priority Watch List,’ which could potentially lead to trade sanctions against Thailand. Actual sanctions are unlikely, but Washington and its pharmaceutical allies have made a serious threat. Now that pressure is reportedly being used to block similar licenses for three cancer drugs”

Below, I’ve reprinted the rest of Weisbrot’s story. He makes a powerful argument that countries like Thailand are trying to do what is right for their citizens.

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After 10 hours on the job, a truck driver must pull off the road. After 16 hours, an airline pilot can no longer legally fly a plane. But after 24 hours or more on the job, with perhaps an hour nap somewhere along the line, a first-year medical resident can perform a surgical procedure, write a prescription, or insert a chest tube.

This introduction to a 2004 article in Focus Online, the newsletter from Harvard Medical, Dental, and Public Health Schools, says it all: we expect doctors to be superhuman.

When you stop and think about it, the expectation that medical residents, especially first-year interns, can, or should, perform incredibly complex procedures with minimal sleep is crazy. Medical researches agree—which is why hospital shifts of doctors-in-training have come under much scrutiny in recent years.

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) created standards to restructure residents’ hours in order to combat fatigue, and the dangerous mistakes that accompany exhaustion. The council’s reforms limited residents’ hours to:

• No more than 80 hours a week
• No more than 6 work days a week, averaged over 4 weeks
• No more than 24 continuous hours of duty, except for another 6 hours of education or transfer of care In-house call no more often than every third night
• No less than 10 hours of rest between duty periods

These changes were meant to benefit not only residents, but also patients: an exhausted doctor is a careless doctor. But for all of the Council’s good intentions, studies show that the ACGME reforms don’t go far enough—residents need more of a break if they are to maximize their effectiveness and ensure the safety of their patients.

How do we know?  Last year, two studies from Kevin G. Volpp, MD, PhD, from the Center for Health Equity Research and Promotion, VA Hospital in Philadelphia, Pennsylvania looked at whether the first four years of the ACGME guidelines had resulted in a meaningful decline in patient mortality—in other words, if the guidelines had saved lines by keeping doctors alert and rested.

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