The Massachusetts experiment in health care reform is all about expanding access.  But it doesn’t try to control costs.  This, in a nutshell, is why it’s running into trouble.

The plan didn’t reform health care delivery, just coverage. Granted, in terms of bringing more people in under the tent, it’s been a success: Since the plan went into effect in 2006, 439,000 people have signed up for insurance—a number that represents more than two-thirds of the estimated 600,000 people uninsured in the state two years ago. This surge in coverage has reduced use of emergency rooms for routine care by 37 percent, which has saved the state about $68 million. (Going to the ER for routine care drives up health care costs by creating longer wait times and tying up resources that can be used to help patients who are critically ill).

But even with these savings, Massachusetts is having trouble funding its plan. Earlier this month the Boston Globe reported that the governor’s office is planning to shift more responsibility for funding to employers. Currently, the Mass. Health care law requires most employers with more than 10 full-time employees to offer health coverage or to pay an annual ‘fair share’ penalty of $295 per worker:  this is called ‘pay or play’, an employer either provides coverage or pays a fee toward the system for not doing so).

To “play” rather than “pay,” employers must show either that they are paying at least 33 percent of their full-time workers’ premiums within the first 90 days of employment, Or that they are making sure that at least 25 percent of their full-time workers are covered on the company’s plan. (In other words, they must be paying a large enough share of the premiums so that 25 percent of their employees can afford the plan they offer.)   

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Recently BuckEye Surgeon offered a compelling window on what it is like to be a surgeon (or, for that matter, any type of physician), and realize that patients think that you are practicing pure science.

First, he admitted that he had been reading Cicero, (yes, that Cicero—the late, great Roman orator and statesman), and had come across a quotation that “grabbed him”:

"For the better he is at his job, the more frightened he feels about the difficulty… about its uncertain fate… about what the audience expects of him."

“Cicero was talking about the stresses that afflict a great orator; the pressure to reproduce the excellence of past speeches,” Buckeye explains. “The audience has come to listen and expectations are high and even one minor insignificant error can ruin the overall impression of an otherwise articulate, inspiring speech.

“In many ways, this is what we’ve come to in medicine. The expectations are almost insurmountable. Infallibility is the performance standard. The delivery of healthcare has been relegated to the category of ‘commodity, like automobiles and hair care products and soybeans. Where’s my warranty, my guarantee? Why did I get an infection? Why didn’t you realize I had breast cancer when it was 0.5mm instead of 2mm? Did you wash your hands well enough before you came into my room?

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I first wrote about Gardasil on The American Prospect online in the summer of 2006, just weeks before the Merck vaccine designed to protect against cervical cancer went to market.

There, I noted that “the hullabaloo began in June when the FDA approved Gardasil, a vaccine widely described as ‘100 percent effective’ in preventing cervical cancer, a disease that kills some 233,000 women worldwide each year. The drumbeat grew louder last month when a federal panel recommended that all American girls and women ages 11 to 26 should be inoculated. And now there is talk that states may mandate the vaccine for all school-age children.

“But before prescribing for the entire population,” I suggested, “it’s worth asking a few questions: Why does the vaccine cost $360 for a three-shot regimen? How much do we know about the new product? And is this a cost-effective use of health-care dollars?”

I reported what we knew at the time:  Although Gardasil was commonly described as “100 percent effective” if you scrolled down far enough in most news stories, you would find that the vaccine is “100 percent effective” against  “only two strains of HPV (human papillomavirus) that causes cervical cancer. And those two account for just 70 percent of all cases. The vaccine has no effect on the viral strains which account for the other 30 percent.”

Read a little further and you would discover that because the vaccine protects against less than three-quarters of all cases, inoculated patients still will need regular Pap smear tests to check for signs of the disease.

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What this country needs is more lobbyists, representing more interests groups.  This is what Nicholas Lemann, Dean of the Columbia School of Journalism, all but declares in a contrarian piece published in a recent New Yorker. Basing his argument on The Process of Government: A Study of Social Pressure, a classic written by Arthur Fisher Bentley in 1908, Lemann declares that in the end, politics is all “about interest groups struggling against other groups and finally making deals, through politicians and agencies and courts.”  And this, he implies, is the way it should be.

Under Bentley’s rules there is no such thing as “the public,” Lemann explains. “There are only groups.” And “the public interest” is a “useless concept,” because there is “nothing which is best literally for the whole people.”  Bentley dismisses any idea of what I might call “the public good.”  We live in a society divided against itself, in groups with very discreet, often warring interests.  So much for making common cause for the common good.

As I read Lemann’s piece, I could not help but wonder:  what does this mean for national healthcare reform?  And I realized that there are some reformers who endorse something uncomfortably close to the process that Lemann describes.

Like Lemann, they believe that reform can be accomplished only by letting the interest groups duke it out. Big Pharma, the device-makers, hospitals and insurers all should take their rightful places at the negotiating table (after all, they paid our legislators for those seats), alongside primary care docs and RNs, surgeons and radiologists, hospital workers and  hospital administrators,  each group defending its  turf. Then there’s the AARP, the AMA and the AHA, the libertarians who oppose mandates, the progressives who want mandates…But wait, didn’t I leave someone out?

Oh, right, the patients.  When elephants fight, says a Swahili proverb, the grass suffers.

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This post was written by Niko Karvounis and Maggie Mahar

It’s no secret that the wars in Iraq and Afghanistan have stretched the military thin. Indeed, the past few years have seen a steady flow of news stories depicting just how desperate our armed forces are for warm bodies—including reports that the military is “at its breaking point” and has considered non-citizens for service; that states are seeing their largest mobilization of reservists since World War II; and that the army has abandoned the 24-month limit on time that reservists must serve.

Meanwhile, in November, Stars and Stripes reported that the Pentagon was quietly looking for ways to make it easier for people with “minor” criminal records to join the military. In 2007, the share of Army recruits needing waivers for infractions that included stealing, carrying weapons on schools grounds, and fighting rose to 18 percent –up from 15 percent a year earlier.

There’s no shortage of political objections one can level against the military’s never-ending need for manpower, but there are also some profoundly personal issues to consider when reflecting on just how dangerous it is for our military to deploy—and redeploy—so many soldiers. More than 100,000 American veterans have been sent back to Afghanistan and Iraq despite finishing the terms of their enlistment. Imagine what it means to think that you have fulfilled  your duty—and then to find yourself on the way back to hell.

Imagine being told that you will have a year at home before going back to Iraq—and then being ordered back, as the 4th Infantry Division from Fort Hood, Texas  was after a break of only seven months. “It just plays with your head," says one soldier. “The people in Washington think that this is a board game."

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Did you know that three-quarters of the 40 million sightless people in the world don’t have to be blind? According to ORBIS International, a global nonprofit organization, most of the world’s blind population owes its lack of sight to a lack of access to care.

ORBIS’ mission is to eliminate avoidable blindness by "strengthening the capacity of local eye health partners in their efforts to prevent and treat blindness." Through a process that ORBIS calls capacity building, local partners gain "self-sufficiency in eye health care and residents enjoy quality eye health services that are affordable, accessible and sustainable."

As part of ORBIS’s broad-based capacity building program, the organization works with carefully selected local partners on projects typically lasting at least three years. ORBIS has about 100 of these active partners, which include hospitals, health centers, universities and training centers, local non-governmental organizations (NGOs), eye banks and government health departments.

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When Medicare first created a fee schedule, critics suggested that it was a Marxist invention. Nevertheless, the schedule, which lists what Medicare is willing to pay for some 7,000 procedures, has become the master list for physician reimbursement in our health care system:  most private insurers peg their payments to the Medicare schedule.

The notion of deciding the precise worth of some 7,000 diagnostic and therapeutic procedures is mind-boggling. How exactly does Medicare do it?

The process began in the late 1980s when officials at the Department of Health and Human Services decided that the way Medicare paid doctors should be overhauled. At the time, Medicare was reimbursing physicians  based on what was considered “customary, prevailing and reasonable” in a particular market —in other words the “market value” of the service in that region.

Instead, reformers urged Congress to begin paying doctors in a way that reflected the real cost, to the doctor, of providing the service. (This is where Marx comes in: rather than letting the local market decide what a service is worth “the system appears to be based on the Marxist ‘labor theory of value,’” sputtered Susan Mandel in a 1990 piece in the National Review.) 

But to many in Congress, the notion that physicians should be reimbursed for what it costs them to do what they do—plus a reasonable profit—seemed on the face of it, a sound proposal. The problem, of course, lies in determining what the true “cost” to the physician is.

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Did you ever wonder why hospitals run those radio ads?  In the U.S., hospitals are always trawling for well-heeled, well-insured patients—and the doctors who bring those patients through the door.  And now, the Columbia Journalism Review reveals, some TV stations and newspapers have taken the hype one step further, by forming “Unhealthy Alliances” with individual hospitals.

But first consider the larger picture.

In the U.S. hospital advertising began in the 1970s, when the money really began streaming into the health care industry.  Meanwhile, other countries did not allow medical centers to peddle their services to the public. 

Indeed, in the U.K. the National Health Service decreed that hospitals could promote  themselves “direct-to-consumers” just a few months ago, bringing an end to what had been a fairly acrimonious debate.  Dr Laurence Buckman, a leading member of the British Medical Association’s (BMA’s) General Practitioners’ committee, was an early critic of the idea: "Patients want money to be spent on their healthcare, not spent on advertising to doctors so the hospital makes more money. The health service is not about making money, it is about delivering care for patients."

Dr Jonathan Fielden, chairman of the BMA’s consultants’ committee, told the BBC: "It is a sad indictment of government policy to consider spending public money on advertising NHS services when hospitals are having to make cutbacks in patient care…in order to save money."

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You’ve probably heard about “medical tourism,” the traveling of patients to foreign countries in order to receive care. But what you may not know is just how popular medical tourism has become: according to Deloitte LLP, an international consulting firm, an estimated 750,000 Americans traveled abroad for medical care in 2007. Aggressive projections put this number somewhere around 6 million by 2010.

As interest in medical tourism increases it’s important to understand the nuts and bolts behind its allure, and the risks that it poses—both for patients and health care systems at home and abroad.

Saving Money

Over the past few years insurers and employers have warmed up to medical tourism as a way to save money: its cheaper for insurance plans to help fund patients’ trips to foreign doctors who charge much less for procedures than their U.S. counterparts.

The price differentials  are stunning. According to a recent Deloitte report, Thailand, the world’s leading medical tourism hub, saw 1.2 million medical tourists from around the world in 2006. On average, medical procedures in Thailand cost a mere 30 percent of American prices. India, another destination that sees more than 400,000 medical tourists each year, charges just an average of just 20 percent as much as the U.S. Thousands of Americans also flock to Mexico and South America every year for cosmetic and dental surgery, where procedures cost anywhere from 75 to 50 percent less than they do in the U.S.

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Commenting on “Surgeons and Other Physicians: A Cultural Divide,” a reader who recently found himself in an OR with his wife offers his perspective.  This is not meant as a rebuttal to Dr. Cohn’s post. I think that the two perspectives are both equally true—and that OR cultures may vary widely, from one hospital to another.  I would also like to hear some surgical nurses weigh in.

“jd” writes:

“The domination exhibited by physicians, particularly surgeons, is about far more than verbal abuse and yelling. I don’t doubt those defending their experience who say that they haven’t seen many angry tantrums by surgeons. But I think we’re getting distracted by the most extreme displays so that we miss the very real and dangerous power dynamics here.

“I happen to have just been in the OR a couple of weeks ago with my wife, who was undergoing an emergency C-section. It was performed by obstetricians, as most are. There was one attending and one (I’m guessing) resident who was being trained during the operation. Their tone of voice and demeanor was perfectly pleasant throughout.

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