This week, Health Beat is hosting “Health Wonk Review,” a biweekly round-up of the best of health policy blogs. Below, snapshots of posts that we found particularly interesting.

–Maggie Mahar and Niko Karvounis

News about Docs

In the past, Roy Poses has posted on Health Care Renewal (here and here) about the little-known fact that medical schools often fail to pay or otherwise reward faculty to actually teach.

Poses, who has a sharp nose for the ironies of our healthcare system, asks a fair question: “Why are medical school faculty expected to teach in their spare time, and spend their working hours …bringing in large amounts of what is euphemistically called ‘external support’” (a.k.a. $$$$) — while faculty in other schools are actually paid for teaching and other academic activities?

In his most recent post on the topic, Poses points to a story from the (Tucson) Arizona Daily Star reporting that University of Arizona Medical College Faculty are “On the Verge of Desperation.”

“Maybe it has something to do with having to do 10 hours a day of clinical work to bring in ‘external funds,’ and then being expected to teach,” Poses speculates. It turns out that U. of Arizona medical faculty are actually supposed to do three things:  provide high-quality teaching, care for a full load of patients (thereby bringing in the money),  and build a competitive research program—all at the same time.

“This looks like another case of mission-hostile management at a well-known medical school,” Poses observes, “albeit one that is probably representative of problems around the US.” 

Offering us a glimpse of how medical students see the world Scott Shreeve of Crossover Health grapples with the crisis in primary care. Speaking first-hand from his experience as a medical student at the University of Utah, Shreeve notes that there were efforts to convince students that primary care was the way to go, but that “both the message and the messengers were unconvincing.”

Why? Because, as many of us tend to forget, doctors are what economists call “rational actors” just like the rest of us. (Other social scientists have some doubts on this matter, but that’s another post).

According to Shreeve, decisions about specializing “came down to what specialty can provide the best outcome in terms of attaining the quality of life, financial security, and career stability students desire  at a price they are willing to pay in terms of years of training, lifestyle, and financial considerations.

“In the end,” says Shreeve, “the current financial system we have in place creates overwhelming incentives to go into a specialty.”

What Shreeve says about weighing lifestyle issues against costs makes sense. But is anyone else distressed that having an intellectual interest in a certain part of the body (the brain, for example), a particular disease (cancer, perhaps) or being drawn to a particular type of patients (children, for instance, or the elderly) never seems to come up as a factor in the decision-making process? 

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No doubt some of you saw Monday’s story in the New York Times reporting that health insurance companies have begun forcing very sick patients to pay as much as 20 percent to 33 percent of the cost of some of priciest drugs on the market. As a result “patients may have to spend more for a drug than they pay for their mortgages, more in some cases, than their monthly income.”

But this isn’t just a tale about insurers letting patients down. As with so many health care stories, there is more than one villain in this piece, and plenty of blame to spread around.

First, let me re-cap the background to the Times’ report.  Normally, insured patients are not required to shell out a percentage of what a drug costs. Instead, they just chip in a flat co-pay of $10, $20, or $30, depending on whether the insurer lists the drug on tier 1, tier 2 or tier 3. But now insurers have invented a new category—tier 4—for hundreds of super-expensive drugs used to treat diseases like multiple sclerosis, hepatitis C and some cancers. Since some of these drugs can cost $100,000 or more a year, a 33 percent co-pay can add up to $33,300.

Insurers began this practice with the infamous Medicare Advantage plans that we wrote about on HealthBeat the other day. Eight-six percent of Medicare Advantage (MA) plans now require whopping co-pays for tier 4 drugs, so read the fine print before signing up for an MA policy. And now, tier 4 is showing up in insurance policies that people under 65 buy on their own, or through their employers. This is the fastest growing segment in private insurance, Dan Mendelson of Avalere Health, a research organization in Washington, told the Times.

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The first controlled medical trial in world history was staged in 1601 by a British ship captain named James Lancaster, reported Professor Ajit Lalvani, head of the Infectious Disease department at the Imperial College Healthcare in London, at the World Health Care conference last month.

Four ships were traveling from England to India around the Cape of Africa, Lalvani explained, when Lancaster decided to give the sailors on his ship three teaspoons of lemon juice every morning. No doubt Lancaster was acting on reports that had come from Sir Richard Hawkins during a voyage to the South Pacific, eight year earlier, when Hawkins had observed that the most effective protection against scurvy appeared to be “sour oranges and lemons.”

As the chart below shows, the hypothesis proved correct: by the end of the voyage, 40 percent of the sailors on the three ships where no one received their Vitamin C had come down with scurvy and perished. On Lancaster’s ship, no one died of the disease.

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This post was written by Maggie Mahar & Niko Karvounis

On Monday, the Bush Administration announced that next year payments to private insurers who offer Medicare to seniors will rise by 3.6 percent. This is a mistake. The last thing that the Medicare Advantage (MA) program needs is more money thrown at it. Indeed, MA has turned out to be a money-eating monster—in large part because the government gave it a blank check when the program was born, under the cover of darkness, in 2003.

It’s worth pausing to remember this breech birth. The Medicare Prescription Drug, Improvement, and Modernization Act (also known as the Medicare Modernization Act) came to the House for final approval at 3:30 a.m. on November 22, 2003.  It was losing, 219-215, until the House Leadership, in a very unusual move, held the vote open for hours while the Leaders twisted arms. At 5:50 a.m. the legislation passed the House 220 to 215.

Representative Nick Smith later claimed that he was offered campaign funds for his son, who was running to replace him, in return for changing his vote from "nay" to "yea. " He subsequently recanted this statement. Nevertheless, the House Ethics Committee and the FBI launched investigations into whether members of the House had in fact offered  Smith a bribe to vote for the measure.

In October 2004, the Committee  issued its report, revealing that “Majority Leader Tom DeLay  admitted that he offered to endorse Smith’s son Brad, who was running for Congress at the time, in exchange for Smith’s "yea" vote on the Medicare bill,” though the investigation couldn’t find out who offered Smith the money.

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Recently, I’ve been reading less-well known health care blogs—and finding some provocative stories.

Below, Edwin Leap–who is a physician and a blogger–tells a story about trying to find a specialist for a very sick child in the middle of the night.

Let me preface Dr. Leap’s story by explaining that, in the past, specialists who had “privileges” at a hospital (to treat patients there and to use the hospital’s very expensive equipment and operating rooms) were routinely “on call” to treat emergency patients. But these days, more and more entrepreneurial doctors are refusing to fulfill what was once seen as a traditional duty—unless they are paid.

In Money-Driven Medicine, I quote the chief operating officer of a rural community hospital who recalls a conversation with a young doctor who walked into his office and informed him that he would no longer be willing to be on call for the ER. When the doctor had signed on with the hospital, he, like all of the other physicians, had agreed to be available to treat ER patients one week a month. Typically that might mean coming into the ER two or three times during that week. But now, he explained, he wanted to spend more time at home with his children. He was not willing to continue answering the calls unless the hospital would pay him $80,000 a year.

The COO was nonplussed. He knew that an additional $80,000 would work out to $2,200-$3,300 each time the physician came in ( He did not ask how the doctor had calculated that quality time with his children was worth $80,000).

“But we have a contract,” he protested.

The doctor nodded: “Times change,” he said easily.

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This week, I have written two posts for TPM Cafe, where I am a regular contributor.

They are part of what will be a three-part series (with the third part going up early next week) titled “The Politics of Health Care Reform.”

I have written about some of this here, on HealthBeat, but I’ve been refining my thoughts, and have added some new material after reading a brilliant piece in the Journal of the American Medical Association  by Dr. Ezekiel Emanuel, director of Bioethics at the National Institute of Health (and, as it happens, the brother of Representative Rahm Emanuel of Illinois, the leader of the House Democratic Caucus).

If you go to TPMCafe, you will find part 2, which I just put up today, at or near the top of the page. At the bottom of that post, you’ll find a link to part 1. (I suggest reading part 1 first).

You may also be interested in the reader’s comments . . .

Should People in Iowa Pay for Spacious Rooms in Northeastern Suburbs?

In part I of this post, I took on the conventional wisdom that an aging population is driving U.S. hospital bills higher. The truth is that a combination of spending on new construction and hi-tech equipment pushed the nation’s hospital bill to $648.2 billion in 2006 —up 7 percent from 2005. The uptick was part of a trend:  since 2000, outlays for hospital care have climbed anywhere from 5.2 percent (2000) to 8 percent (2003) each and every year. As a result, by 2006, spending on hospitals represented nearly one-third of the $2.1 trillion we shelled out for health care that year.

In recent years, much new construction has been designed to house new technology or upgrade amenities rather than add to the number of hospital beds.  There is just one exception to that rule: the suburbs.

“When hospitals do increase inpatient beds,” Paul Ginsburg, the president of the Center for Health System Change notes, “the new construction typically occurs in rapidly growing suburbs, where well-insured patients live.”

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Kevin M.D. has begun publishing op-eds from readers on his site www.kevinmd.com.

Below a “reader take” by WhiteCoat,  an emergency physician who blogs at WhiteCoat Rant.  I think he raises some good questions.

WellPoint and Aetna are now putting into widespread implementation a refusal to pay for what have been deemed "never" events.

The theory for payment denials is that if medical providers are not paid when certain unwanted outcomes occur, situations leading to those unwanted outcomes will be avoided.

Some events on the "never" list legitimately should "never" happen. I can’t think of any way to justify performing surgery on the wrong patient or performing surgery on the right patient, but the wrong body part. The flaw in the insurers’ theory is the determination on whether a "never event" has occurred is retrospective, not prospective. The insurers are focusing on outcomes rather than processes.

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As regular readers know, over the past few months, I’ve been investigating how much we spend on various sectors of health care, and where we might be able to save.

As the chart below shows, 4.5 percent of the $2.1 trillion that we, as a nation, spend on health care goes to private insurers to cover their administrative costs—which include advertising, marketing, underwriting, lobbying, profits for shareholders and  executive salaries that look like telephone numbers. As I discussed in December, that $94.5 billion (4.5 percent of $2.1 trillion) equals the difference between what we pay insurers in premiums, and what they pay out in reimbursements.

The government then takes a sliver of the pie to cover the paperwork involved in funding programs like Medicare, Medicaid and SCHIP. Note that while the government picks up nearly half of our $2.1 trillion  health care tab, and private insurers pay just one-third, the government needs only $52.5 billion (2.5 percent of $2.1 trillion) to cover its administrative costs—significantly less than the $94.5 billion that  private insurers require to cover their profits and overhead.

In January I took a close look at spending on physicians’ services. Not surprisingly, doctors fees account for a large chunk of the pie—22 percent.  Healthcare, after all, is a labor-intensive business; it is not at all clear how much we can save in this sector.

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Every year 325,000 Americans die from cardiac arrest, and around three-quarters of these deaths occur at home. Unlike a heart attack, where blood flow to the heart is restricted, cardiac arrest is a stopping of the heart beat. While heart attacks aren’t usually fatal, cardiac arrest almost always is: research has shown the survival rate to be as low as 2 percent.

Given these numbers, you’d think that automated external defibrillators (AEDs)—handheld devices that shock the heart back to its normal rhythm after cardiac arrest—would be indispensable for any household worried about its health. Philips, manufacturer of the nation’s only FDA-approved, no-prescription-needed AED, says as much on its website; the company insists that “anyone who wants a safer home” should buy its product.

But according to a just-released study from the New England Journal of Medicine (NEJM), having an AED at home actually doesn’t make you any safer. Researchers compared survival rates for a group of 7,001 patients who were organized—along with their spouses or companions—into two groups. 3,506 of them were trained to administer CPR and dial 911 in the case of cardiac arrest at home; the remaining 3,495 underwent the same training, but were also given an AED and trained to use it (i.e. placing the device against the patient’s chest and pressing a button to shock the heart back to its normal pace). The study found that overall survival rates were almost identical across the two groups. 

The patients, who hailed from seven countries, were followed from January 2003 to October 2005. Over this period, 169 of them died from cardiac arrest: 84 in the group that received only CPR, and 85 in the group that also used AEDs. Both groups also saw the same number of successful resuscitations (19 in each). In other words, having an AED at home—and knowing how to use it—didn’t help to save lives. 

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