“What we need is Not health insurance,” Dr, Atul Gawande declared at the Families USA conference in Washington D.C. earlier today. “What we need is health care.”

Gawande, who is the author of Complications: A Surgeon’s Notes On An Imperfect Science, went on to make the point that, “even if a person is on Medicare, that doesn’t mean that he is getting healthier.”

What is fundamentally flawed about our system, he added, is that no one is responsible for making sure that healthcare will be better next year than it is this year. “In 1996,”  he pointed  out, “Americans underwent some 60 million surgeries. In 2008, that number rose  to 100 million. Does that mean that Americans are healthier?” he asked. Or does it simply mean that we are paying for more unnecessary surgeries?  “No one knows,” said Gawande, “because we never measure how well our healthcare system is performing.”

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According to a new working paper by the National Bureau of Economic Research (NBER), as the nation’s hospitals battle for paying customers, they are engaged in a fierce “amenities race.”. What is troubling about the report is that it reveals that many patients seem to care more about rooms with views and pleasant service than just how many patients survive their hospital stays.  (Thanks to Stephen Dubner for calling attention to this report in his Freakonomics column in the New York Times; hat-tip to reader Brad F. for sending me the column.)

In “Hospitals as Hotels” Dana Goldman and John A. Romley, (both of RAND) offer a stunning example of  just how expensive the competition has become: in 2004, a Beverly-Hills-based physician group acquired Century City Hospital in west Los Angeles. The group invested nearly $100 million in improvements to medical care and patient amenities, with "five-star personalized service" including a concierge and nightly turn down; bedside internet portals and.at-screen televisions with movies on demand; and gourmet organic cuisine prepared and served by the staff of chef Wolfgang Puck.” The hospital filed for bankruptcy in August, 2008.

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Many Americans assume that all European health care systems are essentially the same: single-payer, government run systems that were created, from scratch, by wise and benevolent reformers.

Nothing could be further from the truth, as Harvard surgeon and author Dr. Atul Gawande reveals in the most recent issue of The New Yorker. 

In virtually every country, accidents of history have provided the foundation for reforms that are unique to each country.  “Reform” did not mean sweeping change. Instead, each country used the hand that history dealt it, and built upon the system it already had. Gawande suggests that the U.S. should do the same.

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Health Wonk Review, a round-up of some of the best of the last two weeks of healthcare bloggery is up on Jaan Sidorov’s Disease Management Care Blog. Sidorov has set his piece to music; to see what I mean click here.

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As you no doubt have heard, the healthcare blogosphere has been seriously divided on President Obama's nomination of CNN chief medical correspondent Dr. Sanja Gupta as our next surgeon general.

Over at The American Prospect, Ezra Klein liked the pick. Klein sees the surgeon general as "the country's leading medical and lifestyle educator," and it's that role " Klein wrote, that  "Gupta  is uniquely positioned to fill. There's not a doctor in this country with half his media training and experience, nor one with a rolodex of editors and reporters a tenth as large." Klein  also expects that Gupta will be an effective  advocate for the President' s health care plan."Sanjay Gupta, arguably the nation's most trusted health care authority, will be back on TV screens arguing for Obama's universal health care plan, lending it his credibility as a doctor, a trusted media presence, and the nation's surgeon general."

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       When President Obama said “The time has come to put away childish things,” I couldn’t help but recall healthcare reformer Don Berwick, sounding discouraged last winter, as he said “Maybe this country just isn’t mature enough for health care reform.”

         Berwick, who is the president of the Institute for Healthcare Improvement, was referring to the fact that at times, it seems that everyone wants healthcare for all—but no one wants to pay for it. And few want to hear about the trade-offs: that the young, healthy and wealthy will have to help pay for the poor, the old and the sick; that we will have to give up our unreasonable demand  for every test, treatment or drug that we think we want—or have heard of — even if there is no medical evidence that it works.  Most of all, we have to give up the unreasonable expectation that somehow, we can beat death—that if someone does die it’s because she ate too much, or the doctor made a mistake, or the HMO refused to give her that last miracle treatment.  We have come to think of death as an error.

        Turning to the economy, Obama suggested that most of us don’t yet realize what lies ahead: “we are in the midst of a crisis that is not well understood.”  He hints at the need for sacrifice: “it is ultimately the faith and determination of the American people upon which this nation relies. It is the kindness to take in a stranger when the levees break, the selflessness of workers who would rather cut their hours than see a friend lose their job which sees us through our darkest hours.”

        He also reminded us that the economy was weakened, not only by the greed of a few men, but by a “collective failure to make hard choices.”

       In his words, I heard an echo of JFK’s “And so, my fellow Americans: ask not what your country can do for you—ask what you can do for your country.”

       JFK’s speech was more original, and had a stronger cadence:

       “So let us begin anew—remembering on both sides that civility is not a sign of weakness, and sincerity is always subject to proof . . . .

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            \When Tom Daschle testified on the Hill earlier this month he reassured many by saying that as Health and Human Services Secretary, he would be working for healthcare reform “guided by evidence and effectiveness, not by ideology.”  Daschle, like Laszlewski, was suggesting that reform could and should be bi-partisan.  But as I suggested in part 1 of this post,  Daschle is only half-right. Medical evidence should guide our decisions about what to cover; but when it comes to questions of whom to cover—and how much coverage they should receive– we are going to have to wrestle with “ideology."

     For many, the word “ideology” carries negative connotations. This is in large part because,  during the Cold War, we used the word to refer to Communism.   Capitalism, we argued, was not an “ideology”—it was true.  But if you open the American Heritage Dictionary, you’ll find that the word itself is neutral: it simply means: “A set of doctrines or beliefs that form the basis of a political, economic, or other system.”   Those beliefs can be true or untrue.  “It is one of the minor ironies of modern intellectual history that the term "ideology" has itself become thoroughly ideologized,” observes the anthropologist Clifford Geertz in Ideology as a Cultural System. http://www.gongfa.com/geertz1.htm

        Granted, “a set of doctrines” sounds potentially rigid or “doctrinaire.” But there is nothing wrongheaded about having a “set of beliefs” about how a society or an economy should operate. Most of us do have convictions about what constitutes a just or an unjust society. And health care reform is about both those beliefs and science. We can try to sweep that under the rug, but I doubt we will get very far. In the debate over health care reform, differences in the ideas that conservatives and progressives hold dear will continue to crop up.

      Conservatives believe that “the market” can solve our healthcare problems. Progressives believe that you cannot count on “the market” to decide in favor of the public good.  I would add that “the market” is not moral or immoral; it is “amoral.” If we want a fair health care system, government is going to have to weigh in with laws and regulations that steer the system toward “the common good.”

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Over at Healthcare Policy and Marketplace Reform, Bob Laszewski reports that “the extension and expansion of the State Children's Health Insurance Program (SCHIP) has now passed the full House and the Senate Finance Committee and is on its way to the full Senate where it will undoubtedly also pass and then be reconciled with the similar House bill.

“However,” he warns, “the way it is being done does not give me a good feeling.

“In the Senate Finance Committee the Democrats were only able to get the support of one Republican–Maine's Olympia Snowe–on the way to a 12-7 approval.

“They did not have the support of the ranking Republican, Chuck Grassley of Iowa.”

Laszewski is worried: “Senate Finance Democrats lost the support of the Republicans when they insisted on departing from last year's bipartisan agreement to leave existing policy on covering the children of legal immigrants as is. As it now stands, a legal immigrant agrees not to apply for Medicaid and SCHIP benefits for the first five years they are in the country. Under the new rules states would have the option of covering legal immigrants. The new bill also left out provisions from the earlier bipartisan comprise to limit benefits for higher income families.

“Without judging on the merits whether these two new provisions should have been in the bill, what the Democrats have done is moved away from earlier bipartisan agreements,” he points out, “ and in doing so lost moderate Republicans like Grassley who showed good faith in reaching an earlier bipartisan compromise.”

He concludes: “As I have repeatedly said on this blog, major health care reform is not possible unless it is bipartisan.”

Here I have to disagree with Laszewski.  Inevitably, healthcare reform will be partisan because it is all about social values—and our beliefs about what is fair.  Progressives tend to emphasize a collective vision of the common good. Conservatives are more likely to stress the rights of the individual.

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Maggie recently wrote about a MedPAC decision aimed at stopping for-profit hospices from purposefully keeping patients under their care for extended periods of time in order bill Medicare for more days of service. Medicare’s concern that the hospices might be bilking the system raises a larger question: should we be worried that so many of today’s hospices are for-profit?

The short answer is “yes,” and at the very least, we should be giving them—and hospices in general—more attention. Hospices play a bigger role in our health care system than ever before. In 2005, hospices cared for 1.2 million patients, and one-third of Americans who passed away that year did so under hospice care. According to the National Hospice and Palliative Care Organization (NHPCO), hospice admissions are rising rising at a rate of almost 10 percent a year.

The fastest growing segment of the hospice industry is—you guessed it—for-profit hospices. Between 1994 and 2004, the number of for-profit hospices in the US increased nearly 4-fold, growing more than 6 times faster than nonprofit hospices. According to industry estimates, for-profit hospice programs now care for about 35% of hospice patients, versus a mere 9% in 1990 (today,  nonprofit groups care for 56% and the government and other types of organizations care for the remaining 9%). Little wonder, given that there’s so much money to be made in the industry:  Medicare reimbursement for hospice care has grown from $68.3 million in 1986 to $8.3 billion in 2005 and is expected to hit a whopping $45.6 billion by 2030.

The bad news is that, in their quest for Medicare dollars, for-profit hospices don’t provide all the care that they should in order to fulfill the hospice mission of maximizing patients’ quality of life. In fact, a 2004 Medical Care study of 2,080 patients enrolled in 422 hospices across the country found that “terminally ill patients who receive end-of-life care from for-profit hospice providers receive a full range of services only half the time compared with patients treated by nonprofit hospice organizations.” That’s because for-profit hospices like to keep costs low by skimping on services, particularly so-called “non-core” services like medications and personal care (How these are classified as “non-core” services I don’t know—they seem pretty important to me—but there you go). For example, families of patients receiving care from a for-profit hospice received counseling services, including bereavement counseling, only [45% as often] as those in a nonprofit hospice. Translation: when researchers controlled for differences across patients, sicknesses, and conditions, those at for-profit hospices were only half as likely to get the same support provided at nonprofit hospices. A 2005 follow-up study confirmed that for-profit patients receive a “narrower range of services” than nonprofit patients.

Given these results, the senior author of both studies, Dr. Elizabeth Bradley of Yale, concludes that “for-profit hospices…might not be as strongly rooted in…[the]…traditional hospice philosophy” of “psychosocial support, spiritual care, the use of volunteers and family, and symptom management” as their nonprofit counterparts.

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