Imagine a society that lets its automakers oversee crash tests on new models, allowing the industry to report results, as it sees fit, to government and consumers. Sometimes, an automaker might not reveal the outcome of a test that turned out badly, deciding that the dummies in the vehicle had been too short—no wonder their chests were crushed!

In other cases, a company might postpone reporting on crash test results for a year or two, hoping that later trials would turn out better. In these cases dozens of trials might be required in order to achieve the desired outcome. The car maker would, of course, pass the additional costs along, in the form of higher sticker prices.

In this society, crash tests are not run and paid for by an independent entity like our National Highway Traffic Safety Administration (funded by taxpayers) or the Insurance Institute for Highway Safety (funded by insurers). Instead, the auto industry itself finances and controls the trials. Automakers also provide most of the funding for the government agency that rules on car safety. Finally, under this system, head-to-head comparisons of cars in a similar weight class are frowned upon. Such trials would create winners and losers—and who wants to be a loser? Instead, each company tests its own cars, and when outcomes finally are published, they tend to be excellent.

Probably you already have guessed where I’m heading.  The system I’ve sketched comes pretty close to describing how we try to assure the safety of the prescription drugs and medical devices sold in the U.S. We may be the only country in the developed world that allows the companies that manufacture and peddle medical drugs and devices to control what we know about them.  The industry also provides much of the funding for the Food & Drug Administration, the agency responsible for weighing the risks and benefits of these products. No wonder the FDA doesn’t require manufacturers to test their products against similar, less expensive products already on the market. Instead, the FDA asks only that the sponsor to test its new entry against a placebo—demonstrating that it is “better than nothing.”

In the U.S., medical research is rife with conflicts of interest. As Merrill Goozner recently testified before the Institute of Medicine (IOM) panel on “Conflict of Interest in Medical Research, Education, and Practice,” the  share of our clinical research funded by industry has doubled over the past 30 years, and now accounts for well over 60 percent of all clinical trials. As a result, Goozner testified, the medical literature is riddled with:

• reports of negative research results being suppressed
• delays in publication 
• failure to report serious adverse events in clinical trials
• the slanting of systematic reviews of medical evidence
• and a systematic bias in research results that favors the outcomes desired by study sponsors.

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Be sure to take a look at the latest edition of Health Wonk Review (HWR) on Joe Paduda’s excellent blog, “Managed Care Matters” (http://www.joepaduda.com/archives/001157.html)

HWR offers a round-up of some of the most insightful health blogs posts of the past two weeks including a post explaining the source of the opposition to universal coverage in San Francisco by Anthony Wright, and a Health Affairs analysis of the  crash and burn of the health reform initiative in California, and Tom Lynch’s four-part post on why the U.S. health care system is nowhere near the best in the world.

Joe himself offers a provocative “modest solution to the ever-growing problem of ever-increasing pharma costs by establishing a cap on national drug costs, allowing the market to figure out the best way to meet that cap, and if the market fails, requiring the Feds negotiate for price and allowing any and all payers access to that negotiated pricing.”

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A couple of weeks ago Dr.  Alicia Fernandez, an associate professor of clinical medicine at UC San Francisco, received a very unusual letter from The International Association of EMTS and Paramedics, an affiliate of The National Association of Government Employees (IAEP/SEIU).

The letter began by noting that Fernandez is part of the union’s approved physician network, and then launched into what can only be described as a shameless sales pitch for Lipitor, Pfizer’s blockbuster cholesterol-lowering drug.

First, the alarming statistics presented in the letter:

• 1 in 3 adults has some form of CVD (cardio-vascular disease)
• About every 26 seconds, an American will suffer a coronary event
• Stroke is a leading cause of serious, long-term disability in the United States
• Every 45 seconds, someone will suffer a stroke. 

Then, the endorsement: “Lipitor is available to our members through their prescription plan. IAEP leadership stands behind LIPITOR as the lipid-lowering agent of choice when it is prescribed by a physician. [my emphasis]  This confidence in LIPITOR is based on its proven efficacy and is supported by its vast clinical experience of more than 15 years…"

The letter went on, at length, to praise Lipitor’s benefits and to downplay the drug’s risks. In clinical trials, the letter states, “the most common adverse events were constipation, flatulence, dyspepsia and abdominal pain.” But while other risks may not be as “common” they are certainly worth mentioning. They include memory loss which can look like Alzheimer’s and severe muscle pain.

A few days ago, Fernandez received a second, identical letter.  Never before in her professional experience had she received a drug ad from a union.

“I’ve never seen anything like this. I’ve never seen Labor endorse a
drug product,” she told me. “This is incredible.” Unfortunately,
Fernandez adds, this is not the
first time that she has seen a drug company use a progressive
organization to promote its product.

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Of the oft-cited “frivolous lawsuits” supposedly decimating our nation, medical malpractice suits are probably public enemy number one—the bogeyman of our medical system that drives the nation’s health care price tag ever higher (or so we’re told).

In reality, medical malpractice settlements and awards account for less than one-half of a percent of our total health care bill—a relatively miniscule amount. Of course a half percent of 2 trillion is still a lot of money, which means that if tort reforms—changes to the legal code that make it more difficult and less rewarding for plaintiffs to sue doctors—were as vital as their proponents claim, we’d end up with some significant savings. But as it turns out, tort reform barely makes a dent on either the frequency of successful malpractice suits or the amount of money our system pays out to them.

A Health Affairs study from last year compared state laws to see if tort reforms have a strong effect on four “outcome variables”: the average amount of a paid malpractice claim, the total number of such claims, the average dollars per practicing physician of a paid claim, and the number of paid claims per practicing physician. Together, these variables comprise what we’re really thinking when we talk about personal injury law suits: how often people win their lawsuits, how much they get, and how these numbers compare to the number of doctors in a given region (in this case, a state).

The study’s authors, who hail from the University of Tennessee, the University of Oklahoma, and the Kaiser Foundation, found that “strong tort law provisions can explain at most only one-fourth of the variation among states in the average payment on a medical malpractice claim.” That means three-quarters of the differences in payment amounts across the states has nothing to do with tort reform!

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In the most recent issue of the New England Journal of Medicine, Dr. Thomas Bodenheimer defines the coordination of medical care as “the deliberate integration of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.” Or, to put it in layman’s terms: doctors working together to get things right.

The value of this sentiment should be self-evident, but the coordination of medical care is more complex than it initially seems—even when discussing admittedly uncomplicated concepts. Consider the “hand-off,” that transitional moment when a patient is passed from one provider  to another (e.g. from primary care physician to specialist, specialist to surgeon, surgeon to nurse, etc)– or is discharged  This transition is unavoidable—as Bodenheimer points out, modern health care necessitates a “pluralistic delivery system that features large numbers of small providers, [which] magnif[ies] the number of venues such patients need to visit.” 21st Century  medicine is too complex for one-stop shopping.

Inescapable though it may be, the hand-off is fraught with pitfalls. As Quality and Safety in Health Care (QSHC), a publication of the British Medical Journal, noted in January, the simple transition of a patient from one caretaker to another represents a gap that is “considered especially vulnerable to error.”

Even the most common hand-off—your standard referral from primary care physician to specialist—is not risk-free. As Dr. Bob Wachter recently noted in his blog, “in more than two-thirds of outpatient subspecialty referrals, the specialist received no information from the primary care physician to guide the consultation.” Sadly, the radio silence goes both ways: “in one-quarter of the specialty consultations,” Wachter says, “the primary care physician received no information back from the consultant within a month.”

These missteps are indicative of what can go wrong during the hand-off, such as, according to QSHC, “inaccurate medical documentation and unrecorded clinical data.” Such misinformation can lead to extra “work or re-work, such as ordering additional or repeat tests” or getting “information from other healthcare providers or the patient”—a sometimes arduous process that can “result in patient harm (e.g., delay in therapy, incorrect therapy, etc).”

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Berlin, March 13, 2008 —  By bringing 600 government and industry leaders together from more than 50 countries, the “World Health Care Congress Europe” (WHCCE),  which began Monday, offered  a splendid  window on  the wide variety of  solutions that countries  around the world are using as they struggle  toward health care reform. One constant theme of the conference: “No One Thing Works.”

When the three-day conference ended yesterday, it also was apparent that developed countries share many of the same problems.  One that stands out is the fact that our populations are aging. Each country faces the same question: how will a shrinking workforce possibly pay for the medicine their nations’ retirees will need?

This brings me to Princeton economist Uwe Reinhardt’s speech on the very first day of the conference. The only American to speak at WHCCE, Reinhardt focused on what he called “the folklore that people bring to the health care policy table.” By nature an iconoclast, Reinhardt spent the next 20 minutes shattering some of the myths that have become part of the received wisdom among policy-makers.

Begin with the notion that an aging population is a major factor driving health care inflation.  In the U.S. this is accepted as a justification for why the nation’s health care bill now equals more than $2 trillion dollars—and why we must expect it to climb ever higher.

Bad news is often more gripping  than good news, and  “if you want to be a popular speaker you need to feed the paranoia of your audience,” Reinhardt  observed, pointing to the first slide of his Power Point presentation—a  chart illustrating just how quickly we can expect a horde of wrinkly boomers to take over the nation. Some stooped and shriveled, others proudly bloated, these former members of the Pepsi generation will be far more demanding, we’re told, than the World War II veterans who preceded them.

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“The rich geographical diversity of the United States is part of its appeal. The diverse performance of the health care system across the U.S., however, is not,” notes The Commonwealth Fund in “Aiming Higher: Results from a State Scorecard on Health System Performance.”

This comparative state-by-state study of care in the U.S. pops off the page as part of a report released this month, “Health Policy Reform: Beyond the 2008 Elections,” and explodes some myths about where the best care can be found.

Find your state on the map below. You may be surprised to discover that when it comes to overall performance, health care systems in states such as New York, California and Texas—places known for being home to some world-class academic medical centers—don’t turn up in the top quartile. (States that do rank in the top 25 percent appear in white).

Reputation is one thing; medical evidence about quality of care, access to care, unnecessary treatments, excessive costs and bad outcomes is another. U.S. News & World Report is good at many things; ranking hospitals is not one of them.

How did the researchers who drew this map rank states? They used the 32 indicators listed on the table below (click to open a larger version in a new window) which measure:

• “Access” (based on how many of the state’s adults and children have no insurance, and how many went without needed care)
• “Quality” (measured by yardsticks such as the percent of adults and children who receive recommended preventive care; the share of hospitalized patients who received recommended care for acute myocardial infarction, congestive heart failure, and pneumonia; the percent of surgical patients who received antibiotics at the right time to prevent infections; the share of Medicare patients who gave the treatment they received high marks and said their provider listened to them, explained, and showed respect; the percent of nursing home patients suffering from bed sores resulting from not having been turned often enough; and the share of nursing home patients who were strapped to their beds)
• “Potentially Avoidable Use of Hospitals and Cost of Care” (measuring how many patients were hospitalized who might not have needed hospitalization if they had received proper care in the first place– and the cost of those unnecessary hospitalizations)
• “Healthy Lives” (indicating the chance of living a long and healthy life in a given state based on the percent of deaths that might have been prevented if the patient had received good care, the percent of breast cancer deaths, colorectal cancer deaths, infant mortalities, and the share of seniors whose activities are limited due to physical, emotional or mental health problems)

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In the latest issue of the Journal of the American Medical Association (JAMA), the always-compelling duo of Ezekiel Emanuel and Victor Fuchs—associated with the National Institutes of Health and Stanford University respectively—dispel the myth of “shared responsibility” in health care financing.

What does this mean, exactly? Simple: “the common claim that employers, government, and households all pay for health care is false. Employers do not share fiscal responsibility and employers do not pay for health care.” In fact, the “money [for health care] comes from [our] own pockets.” 

As simple as this assertion may seem, it’s actually a ground-breaking statement. As Emanuel and Fuchs point out, most of the political rhetoric surrounding health care reform implies that everyone—individuals, employers, households, and governments—struggle with health care costs equally. Implicit in this formulation is a sad tale of businesses getting crunched: Because employers provide health coverage to most Americans who are insured, employers are often singled out as victims. It often seems like the health care crisis is their burden.

Indeed, “burden” is quite the buzzword here. Barack Obama says it’s a tragedy “when businesses have to lay off one employee because they can’t afford the health care for another.” Hillary Clinton notes that “large American companies compete in a global economy against companies in countries that impose far lower health care burdens on employers.” Congress celebrates reforms that supposedly “takes [the health care] burden off employers.” It certainly sounds like businesses have it bad. 

Not so fast, say Emanuel and Fuchs. We need to consider the “health care cost-wage tradeoff.” A large body of economic research shows that, when you crunch the numbers, employers don’t lose the money they spend on health care, but rather take the costs out of their employees’ paychecks. In fact, a 2004 study from the International Journal of Health Care Finance and Economics found that "the amount of earnings a worker must give up for gaining health insurance is roughly equal to the amount an employer must pay for such coverage."

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In Part I of this post,
I discussed the policy implications of recent research from Duke
University showing a clear link between mental disorders in children
and their criminal activity as adults. I particularly focused on the
impact quality child care and poverty reduction can have as a means of
improving mental health—and thus, potentially prevent crime. Part II,
which focuses on education, health care, and the juvenile justice
system, follows below.

But a high-quality continuum of mental health services can’t only
engage with preschoolers. The reality of life is that people develop at
different rates, and the kid who’s quiet at age 3 can become a
hell-raiser at age 9. As such, schools have become a particularly
important site of diagnosing and treating mental health problems among
children.

For all the problems public schools face today, there has been some
progress on the mental health front. The Substance Abuse and Mental
Health Services Administration (SAMHSA) reports that 70 to 80 percent
of children who receive mental health services get the aid from
school-based mental health service providers (e.g. guidance counselors,
school psychologists, etc). Many schools have coordinated programs of
education, observation, and counseling that partner up with community
health experts.

But there’s still a ways to go. The American School Board reports that
there are around 1,700 school-based health centers in the United
States, a tiny fraction of the nation’s nearly 90,000 public schools.
There are many reasons for the relatively small number of centers
including the basic difficulties that come with implementing what
experts call an "ecological" model of mental health. This is a fancy
way of saying that schools that are serious about mental health can’t
just have mental health resources; they must integrate those
resources—educational materials, counselors, information, activities,
etc—into the every day school environment (e.g. classes, discipline,
etc).

This is, as you might imagine, a costly undertaking, and research from
SAMHSA has found that low-income and minority schools are far less
likely to have mental health programs in place. Those that do often
have very limited programs.

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There’s one issue that hasn’t seen much airtime during the Presidential election, and you probably didn’t even realize its absence. That issue is crime, and it hasn’t come up because it’s just not as scary as it was in the past. In one of the great mysteries of criminology, crime began to fall in 1993 and continued to plummet throughout the 1990s and into the 21st century.

Experts have offered explanations ranging from higher incarceration rates to more cops on the streets to the legalization of abortion (this last theory, put forth by economist Steven Levitt in the best-selling Freakonomics, has since been disproved). But ultimately no one can pinpoint exactly what happened, mostly because no one really knows what causes crime as a broad, social phenomenon. If we can’t explain what causes it, we can’t understand what causes it to decline—and thus politicians can’t take credit for it or offer solutions.

But for all the head-scratching, there is one promising line of inquiry that’s only now beginning to see scholarly attention: the link between peoples’ health as children and their criminal activity as adults. Believe it or not, there’s been relatively little empirical work done to link childhood mental disorders and adult offenses. That’s changing. In November, The American Journal of Psychiatry published a study that asked whether “the national crisis in child community mental health services” contributes to “delinquency,” and whether more robust, timely responses to “youths with mental disorders” can reduce adult crime. The answers were “yes” on both points.

The study, carried out by researchers at Duke University, consisted of interviews with a cohort of 1,420 children aged 9 to 13 and a reassessment of these kids every year through the age of 16. During those years, the team identified those youths with mental health problems and diagnosed them. Everyone was tracked until 21 to identify arrests (criminal involvement is far more common between 16 and 20, and drops off sharply when people move into their twenties). The findings were telling.

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