Summary: Today, many argue that the traditional relationship between doctor and patient is changing. At one time, the doctor had the information, the patient listened. But today, as more and more patients trawl the Web, researching their own illness, some are bringing valuable information to their doctors. New websites also offer guides to finding “Credible, Reliable, Objective, Health Information on the Internet” as well as tips on “How to Share Information With Your Doctor” efficiently and tactfully. This is all part of the shift toward “shared decision-making.” Rather than passively giving “informed consent” more patients are making an “informed choice” when they agree to a course of treatment.

Of course, not every patient can—or wants to—become his doctor’s partner. Not everyone possesses the skills needed to surf the web and thread his way through a maze of medical information.  Moreover, many patients (including this one) would rather leave the research to a doctor who keeps up with the latest medical evidence by collaborating and consulting with other physicians.

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Summary: Below an excerpt from “Dirty Medicine” which appears in the July/August 2010 issue of Washington Monthly. The article reveals how “group purchasing organizations”( GPOs) have taken control of the medical supply and  device market.

Originally, GPOs were non-profit collectives formed by medical facilities that hoped to keep a lid on prices by banding together to make bulk purchases of supplies and devices at a discount. But in the mid-1970s, reporter Mariah Blake explains, “the model began to shift. Some large hospital chains started to spin off for-profit GPO subsidiaries, which other hospitals could join by paying membership dues, much the way members of buying clubs like Costco pay dues to get bulk-buying discounts. By decade’s end, virtually every hospital in America belonged to a GPO.

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Earlier this month Senator Orrin Hatch (R-UT) spoke for more than a few conservatives when he declared “We’ve been working to dismantle Obamacare. We have to fight this terrible law that’s a threat to liberty itself.”

Over at the New Republic, Jon Chait offers two reasons why this won’t happen: 1) the American people don’t want it to happen and 2) Republicans don’t want to be voted out of office.

 Chait begins: “One of the political benefits to Democrats of passing the Affordable Care Act (ACA), rather than following the crawl into a hole and die strategy urged upon them in all sincerity by Republicans, is that it shifted the debate to favorable terrain. Now Democrats are favoring the status quo, and Republicans are trying to pass a radical change. Indeed, now that the issue is repeal, it's Democrats who are united and Republicans who are divided, rather than the reverse.” http://www.tnr.com/blog/jonathan-chait/75967/republican-health-care-fratricide#comments

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For now, all those physicians who threatened to make a mass exodus from Medicare can take a breather. Last week, the House voted to once again delay the mandated 21% cut in physician fees by another six months; thereby ensuring that the fight over the sustainable growth rate (SGR) will be resurrected sometime around Thanksgiving.

So far, Congress has kicked the SGR can down the road 10 times since 2003—four times just this year alone. The targets have long been considered unobtainable and the mandated physician payment cuts are opposed in Congress by Democrats as well as Republicans and supported by nearly no one. The level of anxiety among doctors continues to escalate every time the issue is raised—even though the cuts have never gone into effect for more than a couple of weeks. Why not get rid of this devilishly frustrating formula once and for all?

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HealthBeat readers may have read about the death of Polly Arango, a nationally known advocate for children with special health needs, earlier this week.

Over at Running a Hospital, Paul Levy, President and CEO of Beth Israel Deaconess Medical Center had this to say: “Learning of her untimely death in a freak one-car accident in Alamosa, Colorado, [on Saturday, June 16], I felt a blow-to-the-midsection loss.”

Levy met her at last year's Institute for Healthcare Improvement (IHI) Annual Forum (picture here) where Arango served as the Forum’s co-chair.  “She made an immediate and wonderful impression,” he recalls. “After the conference, I was curious. Who was this person? It was then that I learned of her extensive accomplishments.”

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Kaiser Health News (KHN) reports that “the nomination of Dr. Donald Berwick to run the agency overseeing Medicare appears to be languishing.”   Friday, KHN’s “Health Policy Week in Review” quoted a story that appeared in the New York Times a few days earlier:

"Hospital executives who have worked with Dr. Berwick describe him as a visionary, inspiring leader. But a battle has erupted over his nomination, suggesting that Dr. Berwick faces a long uphill struggle to win Senate confirmation. Republicans are using the nomination to revive their arguments against the new health care law, which they see as a potent issue in this fall's elections, and Dr. Berwick has given them plenty of ammunition. In two decades as a professor of health policy and as a prolific writer, he has spoken of the need to ration health care and cap spending and has confessed to a love affair with the British health care system." 

KHN also points out that according to The Hill, although Senate leaders are nearing an agreement to allow more than 60 Obama nominees to be approved to begin work, Berwick is not on the list  . "'He will not get unanimous consent,' a spokesman for Senate Minority Leader Mitch McConnell (R-Ky.) told The Hill.

I am not at all persuaded that Berwick’s confirmation is in trouble.

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Atul Gawande gave the commencement speech at Stanford’s School of Medicine this year. Below, the speech, which was published in the New Yorker http://www.newyorker.com/online/blogs/newsdesk/2010/06/gawande-stanford-speech.html    

Summary:  In his speech, Gawande congratulated the class for ignoring their elders: “You come into medicine and science at a time of radical transition. You have met the older doctors and scientists who tell the pollsters that they wouldn’t choose their profession if they were given the choice all over again. But you are the generation that was wise enough to ignore them: for what you are hearing is the pain of people experiencing an utter transformation of their world.”

Most people do not enjoy radical change that turns their world upside down—and doctors are no exception.  “Doctors and scientists are now being asked to accept a new understanding of what great medicine requires,” Gawande explains. “It is not just the focus of an individual artisan-specialist, however skilled and caring.

 “The volume and complexity of what doctors need to know has grown beyond our capacity as individuals,” he warns. “Diagnosis and treatment of most conditions require complex steps and considerations, and often multiple people and technologies . . . . We’ve been obsessed in medicine with having the best drugs, the best devices, the best specialists, but we’ve paid little attention to how to make them fit together well.”  And because our system is not well coordinated, “more than forty per cent of patients with common conditions like coronary artery disease, stroke, or asthma receive incomplete or inappropriate care in our communities.”

He tells the story of a patient who lost all of his fingers and all of his toes because each doctor thought that another doctor involved in his care had given him the vaccine he needed.

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Accreditation Group’s Proposal on Resident Physician WorkHours Do Not Measure Up to Institute of Medicine Recommendations

Summary: As regular HealthBeat readers know, resident sometimes work 30 hours shifts. In 2008, the Institute of Medicine (IOM) recommended capping shifts at 16 hours, saying that longer shifts are unsafe for patients and residents themselves. Sleep deprivation is likely to lead to errors; residents acknowledge that lack of sleep has caused them to make mistakes that harm, and sometimes even kill patients. Exhaustion also affects how they feel about their patients. I have posted about this here. The IOM also noted that in some cases, residents need better supervision. I told the story of what happened to 15-year-old Lewis Blackman earlier this month.

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Speaking at a Third Way event earlier this week, House Majority Leader Steny H. Hoyer (MD) had this to say about the deficit:

“On the spending side, we could and should consider a higher retirement age, or one pegged to lifespan; more progressive Social Security and Medicare benefits; and a stronger safety net for the Americans who need it most. “

On the face of it, lifting the retirement age makes sense. Americans are living longer, so they could retire later and still enjoy their golden years.

Except—only some of us are living longer.

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As Congress once again wrestles with “the doctor fix”—yet another postponement of the 21% cut in Medicare reimbursement that went into effect this month—the media has been swirling with stories warning of a mass exodus of doctors out of the federal program. The reason: In 2008 Medicare paid doctors 78% of what they get from private insurers; with the 21% cut they fear that their income will drop even lower.

The reports hit their peak late last week—USA Today wrote that “[t]he number of doctors refusing new Medicare patients because of low government payment rates is setting a new high,” while the American Medical Association announced that 31% of primary care doctors are restricting the number of Medicare patients they take. In a recent survey, the American Academy of Family Physicians found that 13% of respondents didn't participate in Medicare last year, up from 8% in 2008 and 6% in 2004. Chic Older, executive director of the Arizona Medical Association told the Seattle Times ; "If the 21 percent cut goes into effect, we're going to have a very severe problem in the state of Arizona."

The question is: Will Medicare beneficiaries really face a shortage of providers and restrictions on their access to care? Or is this a scare tactic being used for political reasons?

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