The most recent Health Wonk Review, hosted by Joe Paduda at Managed Care Matters, raises provocative questions about making health care reform a reality. You’ll find Paduda’s round-up of some of the meatiest health care posts that have appeared on the blogosphere in recent weeks here:  http://www.joepaduda.com/archives/001888.html

Below, a summary of just a few posts, with my thoughts on the topics.  If I had more time, I would write about all of them. I urge you to check out the entire Review.

                                           Gawande: “All Health Care Is Local”

 Paduda begins by highlighting Boston Health News, where Tinker Ready quotes Dr. Atul Gawande saying that “all health care is local.” Ready reports that at a recent health care quality colloquium at Harvard, “Gawande made the case for locally driven reform . . .. Communities, he said, need to find ways to create working systems out of the complex, fragmented elements of medicine.” See Ready’s post here http://tinkerready.wordpress.com/2010/08/17/bhn-exclusive-gawande-on-reform-all-health-care-is-local/

I agree.  When it comes to health care reform, different strategies will work in different regions. In some places, Accountable Care Organizations will thrive; in other medical cultures, doctors will reject the idea of working on salary for a large organization, though they may be willing to take responsibility for outcomes by being paid a lump sum each year to keep a patient well (capitated care.)  In other cities, newly expanded community clinics will succeed in becoming “medical homes.”  In most states, experience suggests that Nurse Practitioners will be accepted (by both patients and doctors) as primary care providers. But in other places physicians and patients just won’t be comfortable with the idea.

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Summary: When I wrote Money-Driven Medicine, the Real Reason Health Care Costs So Much (Harper Collins, 2006),  Rick Scott stood out as one of the more memorable characters in a  rogues’ gallery of CEOs who helped create the stock market bubble of the 1990s.

This week, Rick Scott beat Florida Attorney General Bill McCollumn to win the Republican party’s nomination for governor, shattering campaign spending records by investing $50 million of his own money in the race.  Yesterday, in an interview with CNN, Scott said there is no limit on how much of his own money he would spend in the upcoming election.

The citizens of Florida might want to ask: Where did that money come from?

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Below, an excerpt from an imaginary dialogue between Rick Scott and Rick Scott’s “inner voice”  from Warren Langer’s blog “Still liberal at 83” http://stillliberalat83.net/2010/06/28/rick-scott-republican-candidate-for-florida-governor-talks-to-rick-scott/

It seems, to me, to capture Scott’s inner spirit in an important way.

Rick Scott, Republican Candidate for Florida Governor, talks to Rick Scott

Inner voice: What’s happening handsome?

Scott:         I’ve been thinking of taking over Florida. It’s broken and broke and I can pick it up cheap.

IV:              Peanuts cheap?

Scott:        A few TV spots, some snappy phrases and it’s mine. A state of my own.

IV:              Didn’t you have some problems with that chain of hospitals you ran?

Scott:         I already apologized; said I was the Chief Executive Officer and I was responsible.

IV:             Columbia HCA was fined $1.7 billion for Medicaid and Medicare fraud. Isn’t that a problem?

Scott:         I apologized.

IV:             And that’s it?

Scott:        Hey I not only apologized but said, “Let’s get to work.”

IV:             And that will do it?

Scott:        Look pal, Florida is a state with a collective IQ of 70. They don’t know from Medicare, Medicaid and Quantum Physics which may help in the bathroom. They want me, the next governor, the handsome bald guy, to fix potholes and have slot machines in every condo except for Lake City where they and I are against gambling of any kind except bingo.

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In 2006, when the government began offering prescription drug coverage for seniors through Medicare Part D, the goal was to increase utilization of prescription drugs by the elderly who may not have been able to afford them before, and also to lower the average price of these drugs. The idea was that insurers—representing all the new Medicare Part-D recipients—would be able to use the clout of having this huge market to negotiate price discounts with pharmaceutical companies.

Studies since then—like this one from The Annals of Internal Medicine—have found that Medicare Part D “appears to have led to modest savings and modest increases in drug use by older people.”  With a new provision coming from the Affordable Care Act that aims to help “fill the donut hole” that seniors experience in coverage, these effects should be heightened.

But two new studies have revealed some unintended consequences of Medicare Part D. According to an AARP Rx Price Watch report released today, the retail prices for some of the most popular brand-name drugs sold to seniors increased 41.5% over the last five years, while the consumer price index rose only 13.3%. For example, the drug Flomax (which began facing generic competition this year and is usually prescribed for incontinence due to prostate problems), had the biggest price jump, climbing 24.8% in 2009. Over the past five years, Flomax increased in price by an alarming 92%. Other popular name brand drugs that experienced sharp price increases over that time span include the respiratory drug Advair (40%), the Alzheimer’s drug Aricept (40%), Nexium (28%) and Lipitor (24%)

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Last week I had my first visit with my new primary care doctor. I picked him based on recommendations (plus he’s one of the few that accepts my insurance), and also because he seemed to be an eager adopter of electronic medical records (EMR). On his website, there was a portal for making appointments on-line, asking questions of the doctor and staff by e-mail and once a registered patient, I could also use a secure system to access my medical records. With EMRs being portrayed as key drivers of quality and savings in health reform, I felt encouraged by my new doctor’s embrace of the technology.

But when he greeted me in the examining room, I was surprised to see the medical assistant hand my doctor a pad of paper with my height, weight and blood pressure written on it. As we talked and he examined me, he wrote notes down on the same pad—even though there was a computer in the room. When I asked how he felt about his EMR system, he said it was a great advance for his practice—but unfortunately it had crashed  that morning and the “tech guy” said it might take a while to get it back on track. “By next week or so we should have you in our system,” he sheepishly explained.

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Over at Wachter’s World, Bob Wachter, M.D., Associate Chairman of the Department of Medicine at the University of California, San Francisco  relates what it’s like to be on a plane and hear the airplane’s PA system ask: “If there’s a doctor on board, please ring your call button!”

Wachter has been answering this request for some twenty years and offers a surprisingly candid, wonderfully funny, and ultimately reassuring description of how he has responded. Physicians are trained to be professionals, and most put patients’ interests first.

Over at the New Republic, Jon Cohn reports that the Affordable Care Act gives Kathleen Sebelius great latitude in regulating insurers. And Cohn thinks that she is likely to use it.

“It's not impossible,” to regulate private sector insurers, Cohn writes. “Countries like the Netherlands and Switzerland both have adopted this model with considerable success. But it's a difficult task, particularly in a country like ours without the same tradition of strong regulation and enlightened corporate management.

“The architects of the Affordable Care Act understood this and, to the extent they could, they packed the law with regulations designed to force insurers change their behavior. But, by design and necessity,” Cohn notes, “the law was relatively vague on a lot of matters, leaving final determination of the rules to the Secretary of Health and Human Services and her department.”

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Summary:  Some optimistic liberals have begun to suggest that if conservatives manage to block the Affordable Care Act (ACA) , this  could open the door to better reform legislation.

Why that won’t happen.

       ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~             

If conservatives manage to kill health care reform legislation, what will happen next?

I really don’t want to go there.

First, I’m convinced that conservatives won’t be able to repeal the Affordable Care Act (ACA).  Democrats will hold onto the Senate, and President Obama still has a veto. If necessary, he will use it to protect the bill. Meanwhile, the majority of the public either favors the legislation or want to “wait and see” how well it works. Most voters would be utterly disgusted if Congress returns to the health care debate this fall. It was ugly the first time around; virtually no one wants to watch re-runs on C-Span.  In the months ahead, Americans hope that their elected representatives will do just three things: create jobs, create jobs, and create jobs.

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After the House voted this week to approve a $26 billion aid package to states—$16 billion of which will go toward helping keep strained Medicaid programs limping along—Rep. Joe Barton, of Texas, the ranking Republican on the House Energy and Commerce Committee who voted against the measure said; "There is no emergency," "There is no pending financial catastrophe." House Republican leader John Boehner called the aid package a “payoff to union bosses and liberal special interests.”

What alternate universe do Barton, Boehner and many of their fellow Republicans who opposed the aid package live in? States of all stripes—red and blue alike—are facing a deep crisis in their Medicaid programs.Women and children are losing benefits, and eligibility requirements have only gotten more stringent.

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