The newest edition of Health Affairs includes the story of Michelle Mayer, a patient whose odyssey seems to validate consumer-driven medicine—at least on the surface. But a closer look reveals that Mayer’s tale is no consumerist parable; in fact, it’s a great example of consumer-driven medicine’s shortcomings as a model for health care.

Mayer’s Story

At first glance, Mayer’s story seems to jibe with the ethos of consumer-driven medicine, with a well-informed, assertive patient cycling through obstinate doctors until she finally receives care that she felt was appropriate. The journey begins twelve years ago, when Mayer—a research assistant professor at the University of North Carolina School of Public Health—noticed swelling in her hands and was found to be producing a specific antibody associated with scleroderma, an incurable chronic autoimmune disease. Though Mayer “truly believed that [she] had scleroderma,” doctors diagnosed her with a less serious condition called Raynaud’s phenomenon.

But over the next year, Mayer began to experience symptoms consistent with scleroderma, like sluggishness, hardened skin, and uncontrollable itching. When she finally sought out a new rheumatologist, he confirmed that she did indeed have scleroderma. Irate that her passivity had contributed to the misdiagnosis of her condition, the then-newly graduated Mayer “put [her] new Ph.D. in public health to good use, devouring the medical literature on scleroderma.”

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This week the Disease Management Care Blog hosted Health Wonk Review, and did it with style. (http://diseasemanagementcareblog.blogspot.com/2008/09/welcome-to-health-wonk-review-political.html)

Spotlighting some of the best health blogs of the past two weeks, Jaan Sidorov noted that Joe Paduda, editor of Managed Care Matters, took on the “Free marketeers who have been lauding Gov. Sarah Palin’s efforts to eliminate Alaska’s restrictions on new health care technology and facilities.”  Paduda reminds his readers that we have “a long line of well-documented, rigorously-researched studies that clearly and unequivocally prove supply drives health care costs. The more health care facilities, beds, technology, the more physicians and care givers there are, the higher the cost and the worse the outcomes.”  In other words, there is good reason to restrict how much medical technology we purchase. If we buy more than a community truly needs, we’ll wind up with more overtreatment—and patients will suffer.

Meanwhile, Sidorov reports, over at The Health Care Blog, Matthew Holt has a little fun with America’s Health Insurance Plan’s President and CEO Karen Ignagni.  Its seems that Ignagni occasionally forgets that she earns her $1.3 million salary by heading up a trade group that represents for-profit insurers, and begins talking about how the insurance industry needs to make a profit because it wants to fulfill its “mission.”  As Matthew points out, “No Margin, No Mission” is the motto of non-profit hospitals –institutions that actually do have a social “mission” to serve their communities.

Neil Versel of the Healthcare IT Blog shares the good news and the bad news. The good: Rep. Pete Stark (D-CA) has introduced legislation with some commonsense reforms, including an open source EHR, the promotion of de-identified data use, and clarification of HIPAA. The bad: the likelihood that Stark’s legislation will pass? “Zero.”

Finally The New America Foundation’s  New health Dialogue blog asked Leif Wellington Haase, director of New America’s California Program, and Micah Weinberg, a research fellow in the California program, to update readers on where health reform stands in California. Their entire post is well worth reading, but here’s the punch-line: “Governor Schwarzenegger’s will to pass health reform remains strong, but his approval ratings have tumbled and he even faces the possibility of a recall vote sponsored by the prison guards’ union.”  Only in California.

I’ve traveling, so I’m giving you just a light sampling of this particularly well written Health Wonk Review. Read the entire post by clicking (http://diseasemanagementcareblog.blogspot.com/2008/09/welcome-to-health-wonk-review-political.html

My last foray into international health care systems focused on Singapore, a tiny island nation whose much-lauded health care system represents an interesting public-private mix. But there’s another island, not too far away, that also makes for a compelling case study in health care — in this instance through a single-payer system: Taiwan.

A handful of commentators have already hooked onto the fact that Taiwan’s health care system provides an instructive example of single-payer: Merrill Goozner and Ezra Klein both noted a well-written Congressional Quarterly article on Taiwan’s system earlier this year, and British analyst Ian Williams writes lauds Taiwanese health care in the winter 2008 edition of Dissent magazine.

The buzz around Taiwan’s National Health Insurance (NHI) system stems from the fact that some of its vital stats are stunning, particularly in comparison to the United States. NHI covers 99 percent of the Taiwanese population; in the U.S., 15 percent of the population lacks health insurance. Taiwan spends a mere 6.2 percent of its GDP on health care; the U.S., 16.3 percent. Administrative costs make up only 1.5 percent of NHI’s budget, while administration accounts for about 7.5 percent of American health care expenditures.

Single-payer critics habitually fret about long wait times, but a 2005 article in the journal International Medical Management (IMM) reports that wait-times are almost non-existent in Taiwan, and that Taiwanese doctors cycle through patients speedily enough to “see approximately 50 percent more patients than their counterparts in the U.S. on a weekly basis.” All in all, Taiwanese are far happier with their health care system than we Americans are with ours: last year the national satisfaction rate with health care in Taiwan was 77.5 percent. By way of contrast, an August Commonwealth Fund poll shows that 82 percent of Americans think that the U.S. healthcare system should be fundamentally changed or completely rebuilt.

Admittedly, Taiwan’s single-payer system certainly isn’t all sunshine and rainbows–but it is instructive for those thinking about how to best reform the U.S. system. 

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Princeton economist Uwe Reinhardt is well known as one of the bluntest—and wittiest—critics of U.S. Healthcare.  Last week, we both spoke at a conference organized by Princeton’s Policy Research Institute on “Access to Universal Health Care: New Jersey, the Nation and the Globe. As usual, I learned something from Professor Reinhardt.

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Earlier this year, New Jersey Governor Jon Corzine received a somewhat startling letter from Princeton economist Uwe Reinhardt. The missive was appended to a report from the “New Jersey Commission on Rationalizing Health Care Resources,” a Commission that Corzine had asked Reinhardt to chair.

In the letter, Reinhardt expresses “some personal observations on the inconsistent expectations Americans have of their health system,” describing “these inconsistencies” as “a form of cognitive dissonance.”  Reinhardt goes on to explain that, in his view, these inconsistencies reflect “certain deeply ingrained traits in American culture that stand in the way of a rational health care system.”

He concludes: “In short, Governor Corzine, in my professional view, the extraordinarily expensive, often excellent just as often dysfunctional, confused and confusing American health system is a faithful reflection of the minds and souls making up America’s body politic.”

After reading the letter, Governor Corzine had one question: “You’re not going to publish this in the report, are you?”

In fact, the letter did appear at the front of the report. And last week, at a conference on “Access to Universal Health Care: New Jersey, the Nation and the Globe” sponsored by Princeton’s Policy Research Institute, Reinhardt circulated said letter.  It served as a good companion to Reinhardt’s speech, which compared what we euphemistically call our health care “system” to systems in other parts of the world.

Reinhardt began his talk by considering the fact that, in the U.S. insurance is often tied to one’s job.
“No one –in his wildest dreams—Drunk!!—would design a health care system based on employment,” Reinhardt declared, barely containing his outrage at such a truly bone-headed idea. After all, the unintended–but inevitable– consequence of an employer-based system is this:  if you lose your job, you also lose your health insurance—at exactly the worst possible time.   

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Merrill Goozner, editor of GoozNews, broke this story first in Integrity in Science Watch, published by the Center for Science in the Public Interest, and then reported it on GoozNews.

The post deserves maximum exposure because it illustrates just how underhanded the FDA has become in recent years—while posing as a regulatory agency.

It seems that the Food and Drug Administration turned to “a non-profit run by a pharmaceutical industry advertising consultant to help design its new campaign to educate consumers about direct-to-consumer drug advertising. The FDA’s recently launched website, “Be Smart About Prescription Drug Advertising: A Guide for Consumers,” was developed by EthicAd, a non-profit run by Michael Shaw out of the offices of Atlanta-based Shaw Science Partners. Shaw’s firm claims credit for having helped launch over 25 pharmaceuticals, including Viagra, Celebrex, Zoloft, Cymbalta, and Rezulin, which was later withdrawn from the market because of safety concerns.”

Goozner points out that the site, “which claims DTC ads ‘can provide useful information to consumers,’ focuses its home page on examples of legally correct and incorrect ads—information more useful to ad designers who want to avoid running afoul of FDA regulations than to consumers. It does invite consumers to report violations of the law to the FDA’s division of Drug Marketing, Advertising and Communication.

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In February 2007, William Winkenwerder Jr. announced he was stepping down from his post as assistant secretary of defense for health affairs following a press conference in which he downplayed the Walter Reed scandal as a mere "quality-of-life experience." In the months that followed, it seemed clear that Winkenwerder’s negligence may have been partly to blame for the deplorable conditions at the military hospital.

Now, more than a year and half after his departure, Winkenwerder’s legacy lives on in a multibillion-dollar Defense Department electronic medical-records (EMR) system that many military doctors believe is fatally flawed. One military physician, speaking anonymously, calls it "another Walter Reed-type scandal."

And now, as I noted in a piece that Mother Jones magazine posted this morning, it turns out that the Defense Department’s foray into the world of healthcare IT, a system dubbed AHLTA, is going to cost taxpayers somewhere in the realm of $20 billion—four times what the government had originally budgeted.

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Over the past few months I’ve twice posted about AHLTA, the poorly-designed, unreliable, and costly EMR system that the Department of Defense introduced in November 2005.  In my first post on the issue in June, I noted that one fundamental problem with AHLTA is that it shouldn’t exist: in contracting with an IT firm called Integic to develop the AHLTA software, the Defense Department has actively ignored the Veterans Administration’s successful VistA system as a promising option for building up the military’s EMR capacity.

Last month, my second post focused on the unhappy military clinicians who are forced to use AHLTA  to manage their patient records. Over the summer, the DoD held an online town hall to collect the comments and thoughts of military doctors on AHLTA, and the response was overwhelmingly negative. Participants said that they were “completely disappointed” with AHLTA, and that the system is “a debacle,” too slow and unreliable to be anything besides an “impediment to…seeing patients in an expeditious manner.” The message of the town hall was crystal clear: the Defense Department had spent over $5 billion in taxpayer money to develop an EMR system that its own doctors don’t want to use. 

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At “Number Needed to Treat,” Josh, a public health expert and blogger, provides a welcome addition to my recent post on med school tuition http://numberneededtotreat.wordpress.com/2008/09/09/how-about-the-cost-of-applying-to-medical-school/

I wrote about how the cost of med school narrows the pool of applicants. Josh explains that even the copy of applying is well beyond what many students (and their families) can afford.

Josh writes:

“What struck me about Mahar’s discussion of the subject was a quote at the end of her article:

“According to the NEJM, a recent national survey of under-represented students reveals that the cost of attending medical school was the number-one reason they did not apply.

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       The post below,  "Free Tuition For Medical Students?"  (Sept. 9),  began a dicussion on the
"comments" thread about why med school education is so very expensive.

       Wouldn’t it be cheaper if students did more of their learning online?  Don’t they take a great many courses that ultimatley will be of little help in their chosen specialty?

       If you’re interested in my answer, see the reply I posted today, addressed to Barry and Red Baron at the top of the "comments" thread.

If there are such things as universal truths, then one of them is almost certainly this: nobody likes to be in pain (okay, maybe masochists). This simple assumption is the key principle behind palliative care, which focuses on reducing the severity of pain and managing symptoms of patients with advanced illness—instead of relentlessly concentrating on trying to cure a condition. As many have put it before, palliative care is about caring, not curing—helping patients feel better, sometimes through medication and sometimes through communication and personal support.

Palliative care seems like a practice that would be somewhat at odds with American-style medicine, which centers on maxing out detection efforts and treatment interventions. The reasons for this tendency are two-fold: in our warped reimbursement system, doctors get paid more to do more procedures, and our medical culture is very much focused on ‘beating’ sickness instead of treating people.

Yet palliative care has been on the upswing in American medicine over the past few years. According to the American Hospital Association, as of 2005, 30 percent of U.S. hospitals and 70 percent of hospitals with more than 250 beds had a palliative care program—an increase of 96 percent from 2000. What’s behind this surge?

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A few days ago over at The Health Care Blog, Robert Laszewski posted a list of Sarah Palin’s health care priorities while serving  as governor of Alaska. Number one on her list was the repeal of certificate of need (CON) laws in the state. Such laws give state planning agencies the final say in approving the construction and development of a new hospital, nursing home, or medical service center. Simply put, in the 36 states currently regulated under CON laws, nobody can build a hospital or introduce a new hi-tech device such as magnetic resonance imaging (MRI) scanners without first getting government approval.

This approval is based on “need” and “quality assurance.” Basically, the planning board asks whether a given community could benefit from a service or facility and if those services can be delivered effectively over time. In theory, the main goal of such a vetting of facilities is to reduce health care costs: by regulating the supply of health care in a given region, CON regulations are meant to limit the proliferation of expensive, medically unnecessary services. 

On paper, CON regulations sound exactly like the sort of policy that we at Health Beat have been advocating for a while now: one that realizes an all-you-can-eat buffet of health care options drives up costs without improving quality. Yet CON regulations haven’t been as successful as supporters hoped—not just by the ideological standards of free-marketeers, but also in terms of empirical impact. Why is this so?

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