By Maggie Mahar

Writing on Health Care Policy and Market Place
Review over the week-end, Bob Laszewski called what happened in the Senate last
week : “ the most amazing turn of events I have seen in 20 years of following health care policy in Washington, DC.”

It all began Tuesday, when the House voted 355 to 59 to block a pay cut for physicians. As regular
readers know, Medicare is scheduled to slash physicians’ fees tomorrow (July 1)
by an average of 10.6 percent across the board. Another 5 percent cut is
scheduled for January 1, 2009. Some physicians have
threatened that if legislators take an axe to their fees, they will stop taking
Medicare patients

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This week, over at Disease Management Care
Blog Jaan Sidorov hosts Honk Wonk Review, a compendium of the best
health care posts of the past two weeks. Sidorov offers a tasty buffet, with
links to all of the posts.

 Just a few highlights:

At Health Access
Anthony Wright  is on the news as he  rails against private insurers who explicitly factor in gender (care to guess if males pay
more or less?) and a past history of a caesarian section in their health insurance pricin . (Elizabeth
Edwards also weighs in on this topic here.)

On InsureBlog, H.G. Stern reviews Fed Chairman Ben Bernanke’s pessimistic economic assessment of
health care. “It costs a lot. It’s going to cost more. Information tech
doesn’t hold a candle to growing demand paired with . . . ever pricier treatment options. And we
are all going to pay for it.”

Julie Ferguson, of Worker’s Comp Insider fame, posts about I.T.
behemoth Google’s foray into the electronic medical-personal-health
record with links summarizing both the benefits and the problems.

To peruse the full
menu go directly to Disease
Management Care Blog.

“It seems that John McCain may have stolen some of the fire that
Democrats traditionally wield on health issues by making cost
control his top priority, rather than universal coverage.” –Rob
Cunningham, “Health Affairs” May/June
2008

Last week, the bold proposal for health care reform that Dr. Ezekiel Emanuel
outlines in Healthcare, Guaranteed drew
high praise from the American Prospect’s
Ezra Klein. As
Klein described it:

Emanuel’s Guaranteed Health Care
Access Plan maps out “a total transformation
of the system.  It does not build on the
inefficiencies of the current structure, preserving them in amber for the next
generation.” 

Rather than expanding on the
dysfunctional system that we have today, Emanuel, who is the director of
bioethics at NIH (and brother to politician Rahm Emanuel), is calling for
structural reform. This is what makes his proposal both brave and fresh.

But Emanuel’s plan isn’t just
exciting; it’s practical. As usual, Klein cuts to the heart of the matter: “the big deal, he explains is
cost control. In health care, cost control is everything.”

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If you’re feeling disillusioned about medicine—and physicians—take a look at the Buck-Eye Surgeon’s musing on week-end rounds here.   

I think you’ll enjoy it.

He also takes on the sticky question of specialists who are underpaid–and who might be overpaid–by dividing doctors into two groups: (1) The "Hit and Run Bandits" and (2) The "You Operate, You Own It Crew.”

The idea of “comparative-effectiveness” research has become a hot topic in health care circles. Conservatives are adamantly opposed to it—as are drug-makers, device-makers and even some physicians who have become involved in designing and profiting from new tests and procedures. They don’t want to see their products and services subjected to head-to-head comparisons with the less expensive rivals that they hope to replace. After all, they know that they might lose.  As medical research shows, often, what is “newest" isn’t best.  And with billions of dollars at stake, who wants to be a loser?

But if you think that any mention of comparative-effectiveness research pushes buttons, try talking about appraising the “cost-effectiveness” of medical products and procedures—i.e. asking whether the benefit justifies the price tag. For example, is it really worth paying $100,000 for a drug that will give the patient an extra six months of life?

Often, the two ideas are confused. Indeed, those who oppose health care reform argue that any attempt to set up a Comparative-Effectiveness Institute (as presidential candidate Barack Obama, among others, has suggested) inevitably puts us on a slippery slope headed straight toward making medical decisions based on “cost-effectiveness.”   Before long, the conservatives say, Medicare will be denying treatments simply because they are too pricey. 

Yet, is it such a terrible idea to take cost into consideration?  In a recent issue of the Annals of Internal Medicine, the American College of Physicians (ACP) argues that the United States needs to invest in a national entity that would generate information on both clinical comparative-effectiveness and cost-effectiveness. According to ACP, by failing to make such information available, we undermine efforts by payers, physicians, and patients to make effective, informed choices that optimize the value they receive for their health care dollars.

In the same issue of the Annals, health care economist Gail R. Wilensky, a senior fellow at Project Hope, disagrees, arguing that it is “vitally important to keep comparative clinical effectiveness analysis and cost-effectiveness analysis separate from each other.”  If you talk about “comparative-effectiveness” and “cost-effectiveness” in one sentence, you could doom both ideas.

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This post was written by Maggie Mahar and Niko Karvounis

Every now and then HealthBeat takes a look at health care systems in other countries So far we’ve tackled Germany and China. Next on our list was the Netherlands, but it turns out Health Affairs beat us to the punch. In May, Wynand van de Ven and Frederik T. Schut, two professors at Erasmus University in Rotterdam, authored an excellent profile of the Dutch health care.

Why should we care how they deliver health care in a tiny country most of us will never visit? Few European health care systems have garnered the kind of attention from Americans that the Dutch system has received.—especially from folks not known for their Euro-philia, including the Bush Administration. In the fall, the White House sent a delegation to the Netherlands to learn more about the Dutch system.  The Wall Street Journal also has praised the Dutch system for accomplishing “what many in the U.S. hunger to achieve: health insurance for everyone, coupled with a tighter lid on costs.”

What could make conservatives entertain the possibility that we might learn from Europeans? Under the Health Insurance Act of 2006, the Dutch have created a system of universal coverage delivered entirely through private insurers. In this, the Dutch plan is very much like the plan Dr. Ezekiel Emanuel proposes for the U.S.  in his new book Healthcare, Guaranteed. (We wrote about Emanuel’s plan here  and here), calling it a “fresh” proposal for reform.)

Consumers Have Choices

For those Americans uncomfortable with the idea of “Big Government” delivering their health care, the Dutch model is appealing. And Americans are bound to like the idea that consumers have many choices:  according to the Commonwealth Fund, there are 14 private insurance companies in the Netherlands and several related subsidiaries. This means that individuals can shop for insurance—a process made all the easier by a Dutch government web site “where consumers can compare all insurers with respect to price, services, consumer satisfaction, and supplemental insurance, and compare hospitals on different sets of performance indicators.” Thus, much to the delight of consumer-minded health care reformers, the Netherlands has essentially institutionalized comparison shopping.

Individuals also have the option of paying extra to beef up their benefits package. Van de Ven and Schut note that the Dutch can buy “supplementary insurance for benefits that are not included in the mandatory basic insurance, such as dental care for adults, physiotherapy, eyeglasses, alternative medicine, and cosmetic surgery.” More than 90 percent of the Dutch population takes advantage of this option –which suggests that the supplementary insurance is not too expensive for the vast majority of the population.  Van de Ven and Schut tell us that “most people [purchase their supplementary insurance] from the same insurer that provides their basic coverage.”

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In the days and weeks before they die, fifteen to twenty percent of terminally ill cancer patients receive “palliative chemotherapy.” Their doctors do not expect chemo to cure them. Why then, do they receive it?

In “The Role of Chemotherapy at the End of Life: When Is Enough, Enough?", Drs. Sarah Elizabeth Harrington and Thomas J. Smith explain:  “Chemotherapy for metastatic solid tumors such as lung, breast, colon, or prostate cancer rarely if ever cures patients. The indication for such chemotherapy is to improve disease-free or overall survival, relieve symptoms, and improve quality of life.”

In the article, which appeared in the most recent issue of JAMA, Harrington and Smith tell the story of Mr.L., a 56-year old businessman who is determined to fight the lung cancer that has spread to his spine and brain. Even when his oncologist recommends that it is time for Mr. L. to shift over to hospice care, Mr. L. refuses.   

“You know my husband was extremely determined to remain positive, and he never was going to give in [to the fact] that this could eventually kill him,” his wife reports proudly. “It didn’t really dawn on my husband that he was going to die until he was in the hospital with pneumonia, which was two weeks before he passed away.”

Near the very end of Mr. L’s life, the hospital staff called in a palliative care specialist to help Mr. L. face the fact that he was dying and to consider his options.

Chemotherapy had helped him during the first eight months after he was diagnosed, but during the last six months of his life, as his condition deteriorated, the medical staff felt that because the cancer had spread to his brain, “he was not making informed choices and had lost opportunities to do other  important things with his remaining time while pursuing further  chemotherapies and clinical trials.”

The palliative care specialist believed that he should have been called in sooner. Arguably, Mr. L. needed an oncologist like Dr. Peter Eisenberg, who I quote in part 1 of this post: “Most oncologists don’t talk about the important stuff. They just say, ‘In six to eight months, if this doesn’t work, we’ll try Plan B…”

By contrast, Eisenberg levels with his patients: “I ask them: ‘How do you want to spend the rest of your foreshortened life? Do you want to spend it hanging out with me and my staff [going through another round of chemo]—or do you have something else that you want to do?’”

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A few weeks ago, I had just come home from work when I heard a soft knock at my apartment door.  I asked “who’s there?” and could barely hear a very small voice replying. 

I opened the door and saw a tiny woman: skeletally thin, bald– just a few tufts of dark hair standing up on a bruised skull. Her dark eyes were enormous.  After a second of shock, I recognized her as my long-time neighbor, Anne.

I don’t know her well, but by instinct, I put my arms around her and tried to hold her.

She pulled back: “Please don’t,” she said, and she began to cry.  “I’m so very sick. I hurt everywhere. It hurts when you touch me. I even screamed at Alan on the street,” she said referring to her husband, “when he tried to pat my back.”

I knew that Anne had suffered from cancer some years ago, and recently, I had heard that it had come back. A neighbor had told me that she was staying with friends in New Jersey while undergoing another round of chemo.

Now she has come home. I believe that she has come home to die.

She has come to me because her husband isn’t home (they separated before the cancer came back), and she can’t get into her apartment. She has two keys for the two locks to her front door and isn’t able to figure out how to use them.

She is apologetic: “The chemo does things to your mind,” she says.

Then she adds, “I’m sorry, I can’t remember your name. But I know you wrote a wonderful book.”

I explain that the fact she doesn’t remember my name doesn’t matter. That she remembered the book is so very kind. “To me, that matters more,” I tell her.

I see the shadow of a smile. She has always been a very gracious woman, and at this moment, she realizes that, despite all of the pain, she still possesses the power to make others feel good.

When we get to her apartment, I open the locks. She won’t let me in—“The apartment is a mess,” she says. “And I just want to lie down.”

I understand that she wants to be alone. I persuade her to give me a piece of paper and write my phone number down, in case she needs something or someone during the night. 

I don’t expect to hear from her. And I didn’t.

But I do find out that her husband is coming every day to visit her and bring her things she needs. I still think she has come home to die.

And I also believe that the chemo that was supposed to help her may have done her more harm than good.  Of course, I don’t know for sure.

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We know that as a nation, we invest well over $2 trillion each year in healthcare. But where exactly do our health care dollars go?  Where are they well-spent and where are they wasted?

In recent months I’ve been trying to answer those questions by looking at healthcare spending sector by sector, analyzing how much we spend on physicians’ services (here  and here);  on hospitals (here and here) ; and what share our health care dollars is eaten up by insurers’ “administrative costs and overhead.”

This post will take a hard look at spending on nursing homes.  As the chart below reveals, the nursing home sector accounts for roughly 6 percent, or $124.9 billion of the more than $2 trillion that we invest annually in healthcare. As always, the question is “Are we getting good value for our money?”  Given how vulnerable nursing home patients are, questions about quality deserve special attention.

Quality of Care

The news is almost as depressing as The Savages. (A powerful film, starring Philip Seymour Hoffman, Laura Linney, and Philip Bosco about a brother and sister who are faced with putting their father in a nursing home.)

Begin with a recent GAO report.  Last month the Government Accountability Office reported that when Congressional investigators double-checked nursing home reports from state inspectors, they found widespread “understatement of deficiencies,” including malnutrition, severe bedsores, overuse of prescription medications and abuse of nursing home residents.”

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Health Wonk Review, a compendium of some of the best health care blog posts of the past two weeks, is up at the ever-informative Health Affairs blog. Be sure to check it out.