Changing Guidelines vs. Changing Practice

It's been a few weeks since an expert panel recommended that the guideline for mammography use be pushed back to age 50 (from age 40). During these few weeks, it was interesting to see how much controversy this understandably generated. As too much screening causes more harm than good, and the panel has demonstrated that this is the case for women in their 40s, physicians and patients alike have opposed the new recommendation and will continue to follow the old recommendation knowing that it only benefits 1 out of 1,900 women in their 40s. I think it's interesting and right in line with our discussion earlier this year on how people react to change. Of course, guidelines are just that, and they likely won't change physician practice in the short run since screenings are administered on many factors such as family history, etc. What about the long run, though?

Health Care vs. Environment/Behavior

This op-ed column in the NYTimes brings up the question of how much of a given disease's burden is attributable to health care vs. behavior. http://www.nytimes.com/2009/12/06/opinion/06kristof.html?_r=2 There's nothing particularly profound about it, but it's a good example of how the public grapples with what we have studied to be the 10%-40% breakdown (10% due to health care, 40% due to lifestyle).

Penny-wise, Pound-foolish

Here is an article about the 10% cut to Medicare-funded home health services proposed in the health reform bills.

http://www.nytimes.com/2009/12/05/health/policy/05home.html?_r=1&ref=health

The NYtimes has done a "close-up" piece on the effects this would have on a home care agency in eastern Maine that is already in the red, complete with a slideshow of the patients they treat.

Though home health services save a lot of money in the long-term by keeping people at home instead of at nursing homes and hospitals, Democrats have proposed these deep cuts to these services because there is "waste and inefficiency" in the delivery system. They hope that the cuts will encourage home health agencies to make improvements, thus strengthening the program. The Republicans proposed an amendment to stop these cuts, and it was defeated by the Democrats.

I do not think that a sudden 10% cut in payments is a good way to spur innovation and improvement - it seems much more likely that it will simply put home health agencies out of business.

Of course, cuts will have to made from existing government programs to pay for health reform, but it is disappointing to see them come from such beneficial services.

Accountable Care Organizations as a tool to help control exploding cost of diabetes?

I came across this article posted on cnn.com: http://www.cnn.com/2009/HEALTH/11/26/diabetes.projections/index.html

A study predicts that the cost of diabetes may triple over the next 25 years, from $113 billion to $346 billion. This figure is absolutely astounding. As we know, diabetes is one of the most preventable diseases, yet we as a society are not doing a particularly good job at preventing or managing it.

This article argues that part of the reason that diabetes is so hard to manage is because its effects are not seen until years later, when the disease has progressed to more severe stages. Accountable care organizations, which offers incentives for insurers and medical providers to encourage early treatment, may hold promise. This is not a novel idea as the UK has a similar system in place.

However, what is needed is greater incentives for patients to take control of their own health care. According to one Dr. Jonathan Gruber, an economist at MIT, putting the patient in control of their own care may help. In particular, he "likes the idea of allowing insurers to charge higher premiums to people who don't meet certain health benchmarks, such as losing weight if they're obese."

As someone with some clinical experience, I believe that one of the most difficult things to achieve in health care is patient compliance. Perhaps directly integrating cost incentives or dis-incentives may be the catalyst to help patients wake up and place their health as a top priority.

Paying for Quality, not Quantity

A new study from the UCLA School of Public Health (I know, I know - groan groan groan...) shows evidence that Pay-for-Performance programs can be more effective if they incentivize better quality in patient-clinician interaction and clinical outcomes rather than physician productivity.

http://newsroom.ucla.edu/portal/ucla/medical-pay-for-performance-improves-112787.aspx

A fitting warning to help avoid making health reform look like the old fee-for-service model...

Health Care: GE Gets Radical

Here's a story on how GE, one of the USA's largest corporations, has moved to offer its employees ONLY consumer directed high deductible health plans. While many companies offer such plans, most offer them as just one of several options. It will be interesting to see if other major corporations follow suit, and compel their employees to take on a bigger share of their healthcare costs.

http://www.businessweek.com/magazine/content/09_48/b4157030792130.htm

US view on global health spending

Sorry for two posts at once, but here's another really interesting study on US views on spending on global health, by he Kaiser Family Foundation - http://www.kff.org/globalhealth/upload/8013.pdf Of note is that even between March and October of 2009 more people shifted towards thinking that US should spend money on global health. At the same time, perhaps contradictorily, more than half of those polled believed that spending to improve health in developing countries would help health in the US (by preventing epidemics), yet less than half believed the US should spend money on global health issues. YET, at the same time, more people thought the US was spending too little money on global health than those who thought it was spending too much. There are lots more interesting trends all graphed out - definitely worth checking out.

Viral load mapping for HIV in SF

SF created a map showing viral loads in HIV patients by neighborhood. Measuring in this way is new, as compared to tracking individuals with the disease or, earlier (before medications made it more controllable) deaths. The map now gives a picture of how HIV is being addressed in different neighborhoods, not just how it's being transmitted. In other words, it's one way of visualizing disparities in care. Could have interested implications for how care is planned and improved. One point it raises is that more work needs to be done to rebrand HIV as not just a "gay disease" (already there's been a lot of work, but not enough) and also to reach out to more diverse cultural, racial and SES groups. Here's more info: http://www.nytimes.com/2009/11/06/health/research/06sfvirus.html

Senate Votes Secured

This is exciting! The system should hopefully become somewhat progressive with the additional half a percentage point increase in Medicare payroll tax for people with an income over 200,000 and a tax on expensive insurance plans.

http://news.bbc.co.uk/2/hi/americas/8372210.stm

Botax

an excerpt from an article I saw today:

"Something called 'Botax' might help pay for health care reform. The name derives from a tax on Botox... which in the case of some Hollywood types could raise millions.

Senate Democrats are proposing a 5% excise tax on elective cosmetic procedures... that includes things like Botox injections, breast implants, tummy tucks, face lifts, liposuction, teeth whitening, eyelid repairs, etc."

interesting...well, the money has to come from somewhere?

Health care moving away from actual human care?

A really interesting article in the NYT about how the focus of the medical system is trending towards "checking off the boxes" (i.e. quality indicators, EHRs, etc.) which is indeed contributing to a higher quality of care, but at the same time providing less patient care since doctors pay less attention to patients.

Here's an exerpt:

------

from Checking the right boxes, but failing the patient, By DENA RIFKIN, M.D.
http://www.nytimes.com/2009/11/17/health/17case.html?_r=1

"None of these interventions, however well meant, address a fundamental problem that is emerging in modern medicine: a change in focus from treating the patient toward satisfying the system. The effects of focusing physicians’ attention on benchmarks and check boxes are not, I think, to the patient’s advantage.

A close family member was recently hospitalized after nearly collapsing at home. He was promptly checked in, and an electrocardiogram was done within 15 minutes. He was given a bar-coded armband, his pain level was assessed, blood was drawn, X-rays and stress tests were performed, and he was discharged 24 hours later with a revised medication list after being offered a pneumonia vaccine and an opportunity to fill out a living will.

The only problem was an utter lack of human attention. An emergency room physician admitted him to a hospital service that rapidly evaluates patients for potential heart attacks. No one noted the blood tests that suggested severe dehydration or took enough history to figure out why he might be fatigued.

A doctor was present for a few minutes at the beginning of his stay, and fewer the next day. Even my presence, as a family member and physician, did not change the cursory attitude of the doctors and nurses we met.

Yet his hospitalization met all the current standards for quality care.

As a profession, we are paying attention to the details of medical errors — to ambiguous chart abbreviations, to vaccination practices and hand-washing and many other important, or at least quantifiable, matters.

But as we bustle from one well-documented chart to the next, no one is counting whether we are still paying attention to the human beings. No one is counting whether we admit that the best source of information, the best protection from medical error, the best opportunity to make a difference — that all of these things have been here all along.

The answers are with the patients, and we must remember the unquantifiable value of asking the right questions."

------

I find it difficult not to completely agree with Dr. Rifkin. To me, being in a hospital is scary enough because you're feeling icky. Add to that the fact that doctors are completely impersonal (I haven't seen the same doctor since I was 11)... I and many others have good incentives to stay away from seeking health care. Even preventative care - sure it's good for you, but it seems like such an ordeal.

Medical homes would be a good way to address this issue - Healthy San Francisco seems to be doing a good job at this. HSF provides low cost medical care to low income residents of SF; they've been getting patient satisfaction reviews that have been incredibly good.

Fundamentally though, for real change to occur, I think that the amount of time spent with patient should be a clinical quality indicator. And, perhaps doctors should also be required to undergo multidisciplinary training. Medicine is never purely about science - the biggest reason we bother to take care of our physical health is because it affects our emotional well being. Hmm...maybe M.Ds should be required to take psych classes instead...?

Equity and new technology

I just saw this interesting talk by Ian Goldin, director of the 21st Century School at Oxford. He brought up quite a few issues, but the one that especially drew my attention was his point that we've seen vast improvements in the past half century but increasing inequity. As we move ahead, we'll see even more improvements and improved technology that we can't even imagine. There's a huge and likely danger, though, that that improved technology will not be evenly distributed, and that improved health technologies will only be available to the very top of the pyramid. Then, what happens with the bottom? Inequity in distribution of life-saving and -extending and -improving technology is not "fair," but it's also dangerous. I'm interested, then, to hear both your feedback on this issue and also ideas to increas equity.

No more flu vaccine shortages in the future?

The Wall Street Journal had an interesting article this week on a new procedure that will shorten the time it takes to produce influenza vaccine. Current technologies include the growth of real influenza viruses inside chicken eggs, which can take up to six months. The new technology that is up for FDA approval next week uses genetic material from an influenza virus, which is then inserted into a virus that infects caterpillars. The manipulated cells are then grown in a stainless-steel fermentation vessel for three or four days. This new process will take less than two weeks, and safety and efficacy testing will take another month. Aside from the implications this will have for emergency responses for flu outbreaks in the future, the article also raises the question of how the FDA approves new drugs versus how regulatory bodies in other countries approve drugs. Novartis already has a flu vaccine that is grown in a dog-kidney-derived cell-culture system, which takes one month less than the traditional chicken-egg technology. This vaccine has been approved for use in a number of countries outside the U.S.

Source:
http://online.wsj.com/article/SB125815143285947561.html#articleTabs%3Darticle

In defense of the health insurance industry

Will Ferrell (and celebrity friends) recently created a spoof video speaking out against insurance companies and in support of the public option: http://www.youtube.com/watch?v=B98muhufAGE

It uses sarcasm to portray the insurance industry as the arch enemy of health care reform, claiming that greedy insurance companies make billions of dollars in profit while intentionally taking advantage of those who cannot pay for care. While it's easy to scapegoat insurance companies, it got me thinking that it's important to get the facts. In actuality, for every dollar spent on healthcare in America, 99¢ goes to hospitals, doctors, pharma, other medical services, and other health related spending. Only 1¢ goes to health plan profits. And we need to remember that employees are generally satisfied with their coverage - about 2/3 of employees rated their employer-based insurance coverage as “excellent” or “very good” in a recent survey (National Business Group on Health Employer-based Health Benefits Survey, 2007). Also, the insurance industry has formally supported many of the reform proposals.

Private insurance companies are making profits, but they are certainly slim. Finger-pointing at health plans to portray them as immoral, corrupt, and money-hungry will get us no closer to progress on health reform. I acknowledge there are MANY problems with insurance companies, but I argue that the American system of care is designed to make this the case, not the alleged greed of for-profit insurance CEO's.

Comments? Other opinions?

House, Senate differ sharply on health care reform

http://www.cnn.com/2009/POLITICS/11/09/health.care.congress/

This past weekend marked a major step forward with the House approving a major overhaul of the United States' health care system. There are still major hurdles to overcome, however. The more conservative Senate still has to pass its own version, and this could prove difficult with a smaller Democratic majority and stronger Republican minority. What does everyone think, will the Senate bill contain the public option? Will the employer mandate in the House bill hold up in the Senate? Let me know your thoughts.

Abortion Coverage Debate

This article:

http://www.nytimes.com/2009/11/09/us/politics/09abortion.html?hp

is about the debate on whether federal subsidized insurance plans would cover abortions. I found it helpful because of its information on how abortion is currently covered by health plans.

Some of my takeaways from this article were:

• In 2003, only 13% of abortions were billed directly to insurance.
• About half of employee-sponsored insurance plans currently cover elective abortion.
• A ban on federal-financing of abortions is currently in place. Seventeen state Medicaid programs currently cover abortion by using state funds, the rest do not cover it.
  
• Even if abortion is not covered by federally subsidized health insurance plans, women will be able to buy supplemental insurance coverage for abortions. But it is unlikely that many would, because, as the article puts it, "few [women] plan for unintended pregnancies."

Texting as a Health Tool for Teenagers

Here's a link to a NY Times article that talks about a study in which text messaging was used to help teens with chronic diseases and transplants remember to take their medicines and to come in for regular appointments and lab tests:

http://www.nytimes.com/2009/11/05/health/05chen.html?_r=1&ref=health

There is even talk in the article of a desire for insurance companies to cover some sort of text messaging cell phone plan in the future, as a response to the fact that this technology worked so well in this study until 1/3 of the teens had to drop out because they lost cell phone privileges or could no longer afford to have a cell phone.

Text messaging and other newer technologies (facebook, twitter, email, etc) seem to be coming up more & more as easy & efficient ways to reach the younger part of the population.
In fact, Danielle, Doug, and I were just discussing this today with a few administrative people at Sutter East Bay Medical Foundation. We explained to them why it could be beneficial to get younger patients' email addresses for contacting them, and also revealed an idea of using Twitter for preventive health reminders & information. This just might be a great way for a medical office to show its teen patients that even their doctor has jumped onto the technology wagon :)

Thoughts on new technology? Any other articles that any of you have seen out there on similar topics?

And Speaking of Sugar...

I couldn't help but notice an interesting article about the controversy over American Academy of Family Physicians partnering with the Coca-Cola Company to develop soft drink educational materials. All this reminds me of the debate over tobacco-funded research at Berkeley (the School of Public Health banned tobacco funds in 2004). I take it the the AAFP needs outreach money very desperately, but must it do so in a way that compromises its reputation? We'll just have to see what happens.

http://www.sfgate.com/cgi-bin/article.cgi?f=/n/a/2009/11/04/national/a135617S45.DTL

A spoonful of sugar

Dennis Herrera, SF's City Attorney, just got Kellogg's to stop claiming that Cocoa Krispies boosts children's immune systems. The reporters here, as well as the commentariat, seem to think it's a laughable effort, but I think that if the effort was minimal, it was worth it. It's the kind of intervention we dream up in class exercises, and it's useful to see it pitted against the average citizen's exhausted call for increased focus on more substantive things, like, say, violent crime. Anyway, worth it, I say...

http://www.sfgate.com/cgi-bin/blogs/matierandross/detail?entry_id=50979&tsp=1

The Swine Flu Affair Part II?

Blowing the Shot: What we can learn from the shortage of H1N1 vaccine

As I was reading this article today, I couldn't help but think...this sure sounds like the Swine Flu Affair in its approach to pointing out the shortcomings in the response to H1N1, except that this one is more or less in real time. In the same way that the Swine Flu Affair attempted to bring to light the missteps in the swine flu scare of 1976 in order to learn lessons from the past, this article is quick to point out what lessons there are to learn in our current shortage of H1N1 vaccines.

Here are some of the main criticisms:
* We are using slow and outdated technology to grow these vaccines in hen eggs rather than developing quicker methods culturing the virus in mammalian cells.
* "The Centers for Disease Control and Prevention and the Department of Health and Human Services decided to finish making the seasonal flu vaccine before transitioning to the new vaccine, even as evidence suggested that the new pandemic was going to crowd out the yearly flu."
* "Baxter Pharmaceuticals' H1N1 vaccine Celvapan utilizes the much speedier process of culturing mammalian (monkey) cells rather than hen eggs." This vaccine was tested and determined to be safe, but the FDA was apparently unwilling to take the risk of using a new vaccine technique.

On the policy level, I have not been following H1N1 closely enough to know how valid some of these criticisms are. However, one issue that I found particularly interesting was this repeat issue of seasonal flu vaccine versus swine flu vaccine...which one to focus on. In the swine flu scare of 1976, one of the early issues that the CDC had to decide on was whether to continue to manufacture the Victoria flu vaccine or concentrate all efforts on the swine flu vaccine. They pretty much chose to focus on the swine flu vaccine (making small amounts of the bivalent type). And that was determined later to be the wrong choice. This time around, the focus was put on the seasonal flu. And once again, it is being criticized as the wrong choice because the H1N1 hasn't been following the pattern of the normal "flu season." Well then...it appears that learning from the past may be more difficult than it seems.

WHCE Health Care Reform Panel- Issues of Transparency

I had the pleasure of attending the WHCE's Health Care Reform Panel tonight, where several health care folks debated on the controversial (or more controversial) points of the current health care reform movement. The one that I'd like to discuss is the effect of the public option on the health insurance industry as a whole with regards to transparency.

Here are the (paraphrased, not verbatim) perspectives from a couple of the panelists ...

Catherine Dodd, Interim Director, San Francisco Health Services System: The public option would add value to the health care system because we need transparency in exactly where the money is going. Private insurers don't have to disclose such information, while Medicare (a public option) is required to do so because it is funded by tax dollars and governmental funds. Citizens want to know where how their tax dollars are being spent. If there is a new public option that offers transparency, the competition would push private insurers to provide information on the breakdown of where premium dollars go. They would do this in order to keep their customers from changing to the public option.

Jenni Vargas, VP for Business Development, Stanford Hospital & Clinics: How will the public option keep insurers honest? It won't. It will just be one other competitor in the health insurance industry. The public option would serve the population that insurers are not currently serving, or won't want to serve. Since it won't use underwriting, the public option would be taking in patients that the insurance companies probably wouldn't want to cover in the first place. Customers that are satisfied with their current care won't switch just because their insurers don't disclose the minute details of how each premium dollar is being used.

Thoughts? Agree/disagree & reasons?

Woman loses coverage because she was raped

Hi All,

This is a really sad interview conducted by Anderson Cooper on a woman who was raped and who lost her insurance coverage because of it. She needed to follow standard procedure of taking anti-HIV medications for a month after her rape and ended up getting dropped from her coverage. It'll be interesting to hear what you have to say.

http://www.cnn.com/video/data/2.0/video/bestoftv/2009/10/26/ac360.christina.turner.int.cnn.html

Senator Reid announces public plan with "opt-out" provision

Hey Everyone,

I have some breaking news on health reform. Today, Senate Majority Leader Harry Reid announced that health care legislation will include a public option, however, individual states will be allowed to opt out of the plan. Under this provision, states will be allowed to determine whether the public option is right for them, and if not, they will not be forced to offer the public plan. It looks like Olympia Snowe, the lone Republican supporter of health reform, has stated that she will not support Senator Reid's plans, and wants the public option completely out of the legislation. A link to the article is posted below. Let me know what you think the ramifications of this announcement will be for health reform.

http://prescriptions.blogs.nytimes.com/2009/10/26/reid-to-announce-opt-out-public-plan-today/

Prison Hospice

I read this article with great interest.

http://www.nytimes.com/2009/10/18/health/18hospice.html?scp=1&sq=%22months%20to%20live%22&st=cse

It's about a prison hospice in which inmates work as volunteers. Some of the volunteers have committed murder themselves and most have lost friends because of violence. The experience of helping their fellow inmates as they are dying changes the way they view death. Through this model, inmates have companionship during their last days, and those who are caring for them have a potentially rehabilitative experience.

How much is your life worth?

According to NICE, around $22,750 every 6 months....

NICE is a funny way to refer to an organization whose job it is to approve/deny drugs and medical care to patients. It's a British government agency (part of the British National Health Service), and the acronym stands for the National Institute for Health and Clinical Excellence. They use cost-effectiveness data to come up with these figures!

Here are the main highlights:

"The institute, known as NICE, has decided that Britain, except in rare cases, can afford only £15,000, or about $22,750, to save six months of a citizen’s life.

"Any drug that provides an extra six months of good-quality life for £10,000 — about $15,150 — or less is automatically approved, while those that give six months for $22,750 or less might get approved. More expensive medicines have been approved only rarely. The spending limits represent the health institute’s best guess for how much the nation can afford."

The article talks about a couple where the husband the British health system refused to pay for his treatment for kidney cancer because the drug was too expensive. Hi wife, Joe Hardy, is quoted as saying, “Everybody should be allowed to have as much life as they can.”

The article is a little old - written in December of 2008. Here's the link: http://www.nytimes.com/2008/12/03/health/03nice.html?scp=6&sq=british%20national%20health%20service&st=cse

We talked a little about culture in class at some point (or some class - they all seem to meld into one fairly easily) and how we're just not a society that's very accepting of death...how perhaps attitudes surrounding death need to change before we realize that maybe it's better for our loved ones to spend the last few months of their lives at home instead of in a hospital.

Yup I know - easier said than done...but maybe it would make dealing with death easier if we took only one small step and just talked about it more in our daily lives.

A very rambling post - I hope you found it somewhat useful! I'm always up for talking about death btw. And life. :)

Using holistic medicine to help contain costs?

I was speaking yesterday with the ex-directory of the Osher Center, UCSF's complementary medical center. He is good friends with Andrew Weil (whom he calls "Andy") and other holistic practitioners, but he also trained at both Harvard and Stanford medical schools and was Associate Chief of Nephrology and Medical Director of the Artificial Kidney Center at the Santa Clara Valley Medical Center. (In other words, he's well-versed in both worlds and not easy to dismiss as a "quack") My question to him, and one I raise to you all now as well, is what role could a more holistic approach to health take in the US's attempts to lower costs? I wrote my thesis on Chile's adoption of both indigenous medicine and CAM (complementary and alternative medicine) in mainstream public clinics. By adopting both for very specific conditions, they were able to reach a larger population and save costs. The doctor I spoke with yesterday seemed frustrated, at least partly, by the "reductionism" of modern medicine, how it breaks down health into little tiny portions (looking at each disease and molecule individually) and ignoring interactions. (I'm simplifying for the sake a manageable-length blog post.) His comments, combined with what I'd found in Chile, made me wonder if the US might be able to benefit from incorporating more holistic views of health, and if alternative therapies might in some cases help in cutting back on those 40% of health problems attributable to lifestyle. I'm not talking about prescribing a homeopathic tincture for a heart attack, and I'm certainly not suggesting avoiding vaccines bc they're "not natural", but things like making sure people's nutrition and vitamin intake is balanced (e.g. Had I known two months ago that my Vitamin D levels were low, it's quite likely I would have avoided a stress fracture, saving 5 doctor visits, 9 Xrays, 4 physical therapy visits and over $1000) or making more of a medical point of helping people manage stress. It's quite possible, too, that natural and lower-cost methods could be used to equal or better effect than some high-cost drugs. Before you throw that idea out as quackery - my mom suffered worse-than-usual nauseau from two different chemo regimens. After working through every single anti-nausea prescription her doctor gave her with no result, she finally tried something a bit more natural (legal here but perhaps not NJ yet, so I'll leave it at that) with much better results and none of the awful side effects (except some coughing, which provided some good "laughter therapy").

I'm certainly not saying that we make a mass migration over to alternative/holistic medicine or that we start forcing doctors to incorporate it into their practice or anything radical, but I do wonder if there are aspects of complementary and holistic care that could provide lower-tech, cheaper ways to avoid and handle health problems. It would take research and strict controls to make sure it's done in a safe way, but I wonder if it's even possible or reasonable to bring the two different medical worlds (CAM and mainstream) closer together.

This American Life -- Health Care Edition

Hi all,

I'm sure there are some This American Life fans in our class, so I wanted to point your attention to the last two weeks' episodes of this radio program produced by Chicago Public Radio. Both deal with multiple issues in the health care debate.

For those who don't know, This American Life is a radio show produced by Ira Glass that tells the stories of Americans dealing with ordinary problems to the extraordinary. There are usually anywhere from 2-5 stories per show and they're tied together with some uniting theme.

I know it's a bit more time consuming than reading a NYT article, but if you have 2 hours free, I definitely think these two programs are worth listening to. If not for new information, then for the clever editing and touching and informational anecdotes that experts and lay people tell about their roles in our health care industry. Oh, they're FREE to podcast too!

Links:

Episode 391 - More is Less: http://www.thisamericanlife.org/Radio_Episode.aspx?sched=1320
Episode 392 - Someone Else's Money: http://www.thisamericanlife.org/Radio_Episode.aspx?sched=1321

Also, in case anyone is interested, Ira Glass (the host) will be speaking at Berkeley's Zellerbach Hall on Dec. 5. Not sure if tickets are still available, but this show should definitely be interesting.

When Preventative Care Leads to More Harm Than Good

Preventative medicine is thought to be cost-effective in that diseases can be both prevented or caught in the early stages. However, an interesting article came out in the NY Times yesterday, stating that “some patients are enduring aggressive treatments for cancer that could have gone undetected for a lifetime without [harm].” Furthermore, “some cancers found through screening and treated in its earliest stages still end up being deadly.” This suggests that screening can lead to costly, unnecessary treatments that affect patients’ quality of life without improving survival. Of course, it should be acknowledged that screening leads to good outcomes as well, such as appropriate treatment for aggressive cancers. But where should the line be drawn? When is there too much screening? What should be done to protect patients from being diagnosed with pseudo-diseases and experiencing the psychological and physical consequences of overtreatment?

Link: http://www.nytimes.com/2009/10/22/health/22screen.html?_r=1&ref=health

2 Opinions

Here are 2 different opinions in the health care debate and in support of the public option in particular:

The first is an editorial in the New York Times, "The Public Plan, Continued." The author explains how the Senate Finance and Health, Education, Labor, and Pensions (HELP) Committees must now reconcile their two versions of a bill, the former having struck the public option and the latter still insisting on its inclusion. The opinion of the editorial board lies closer to the HELP Committee's version supporting a strong public option but "with care taken to mitigate adverse effects on rural areas," such as low rates of reimbursement for rural hospitals.

The second is from Robert Reich, former US Secretary of Labor under Clinton and current professor at the Goldman School of Public Policy at UC Berkeley, on his personal blog: "Why Obama Has to do What Letterman Did: Refuse to Pay Hush Money." Reich is critical of both Big Pharma and Doctors, as represented by the AMA, nearly equating their demands on the White House's plan to extortion. He proposes that if the President caves to their demands, it is middle-income taxpayers who will ultimately be forced to provide the hush money in the forms of "still higher premiums, co-payments, and deductibles, higher drug prices, Medicare premiums, and taxes." Reich also warns that if Obama is too soft on the Senate and lets important cost containment efforts fail, we may be dealing with an even scarier prospect than further increasing health care costs: Sarah Palin in 2012.

Policy battle brewing in NYC

This'll be interesting to watch.

NY State Health Commissioner mandates that all health care workers get vaccinated against swine/seasonal flu, but enforcement is temporarily paused under a restraining order while three nurses sue.

http://cityroom.blogs.nytimes.com/2009/10/16/judge-halts-mandatory-flu-vaccines-for-health-care-workers/?hp

Personal liberty is at stake, but so is patient safety. I wasn't aware of this, but apparently vaccination policies for health workers so far have been voluntary; this mandate threatens fines, and even termination. You can see the ferocity of people's opinions in the comments section. What's your take?

Dr. Gupta, Miracle Wrangler

Listening to Sanjay Gupta - CNN star doc and once a buzzworthy possibility for Surgeon General - on the radio the other night, I found myself gritting my teeth. His new book, "Cheating Death," explores medical cases in which the process of death is slowed, then reversed. Excerpt here:

http://www.abcnews.go.com/GMA/Books/read-excerpt-cheating-death-sanjay-gupta/Story?id=8792520&page=4

I'm equally fascinated by the mechanics of death and the tinkering that can take place to subvert it, but something about his framing irked me. The notion of evading the inevtiable being valued above all else - isn't this what's driving our usage and cost and medical-choice-in-the-name-of-freedom?

Won't this eventually swell the cost of emergency care, if more and more Americans demand chilled saline and forced hypothermia to save their loved ones? But putting it in the context of my own parents - would this be something I appreciate about living in America, that I in fact can demand unorthodox treatment?

I don't like the action-hero title, your overly enthusiastic delivery, or your grasping for Jules Verne; but, Dr. Gupta, I kinda see your point.

Reestablishment of the White House Initiative on Asian Americans and Pacific Islanders

Today, President Obama followed Clinton's lead from a decade ago to recognize the needs of the Asian American and Pacific Islander (AAPI) Communities by signing the executive order for the reestablishment of the White House Initiative on Asian Americans and Pacific Islanders, which would improve the quality of life in underserved AAPI communities by increasing access and participation in federal programs. Because AAPI's are continually aggregated together in data and research despite the many diverse groups and needs, they are vulnerable to less federal funding and access to programs that could significantly make an impact. I'm really excited that President Obama acknowledges the challenges AAPI communities face, especially in health and educational disparities due to the "model minority myth" and lack of adequate research. This was the reason why I went into public health in the first place! :)

Some excerpts from his speech:

"It's tempting, given the strengths of the Asian American and Pacific Islander communities, for us to buy into the myth of the "model minority," and to overlook the very real challenges that certain Asian American and Pacific Islander communities are facing: from health disparities like higher rates of diabetes and Hepatitis B; to educational disparities that still exist in some communities -- high dropout rates, low college enrollment rates; to economic disparities -- higher rates of poverty in some communities, and barriers to employment and workplace advancement in others."

"It's the impact of a Department of Health and Human Services that funds research on the diseases that disproportionately affect Asian American and Pacific Islander families. It's the impact of a Justice Department that upholds the Voting Rights Act and its promise of language assistance and equal access to the polls. And it's the impact of evidence-based research and data collection and analysis on AAPI communities -- so that no one is invisible to their government."

To watch the video, go here and skip to the speech: http://www.whitehouse.gov/video/The-President-Observes-Diwali/

Tax Capping - What Do You Think?

I'm far from being an economist, but reading and hearing about tax capping today in 200c was by far the most promising financing mechanism I've come across thus far. I know Professor Dow commented on this at the Healthcare Reform Workshop this past month, but a lot of that frankly flew over my head...but today, it made sense! Wow...I finally saw the light.

I understand that eliminating tax breaks is probably sensitive, but the "Win-Win" article written by Jonathan Gruber was actually fairly enlightening. It was realistic, in that he recognized that eliminating it would be a no-no, and so reducing it would be a good bet. I don't find that so bad now do you? Given that it'll generate a good amount of revenue to fund many of these proposed reforms at the same rate at which costs rise makes total sense to me. Call me naive, but when I was employed, it didn't even occur that my premiums were tax-free, I simply chose the cheapest premium and didn't even make the calculation if I was going to save more in taxes had I chosen a more expensive one! I totally agree with Professor Robinson's arguments for tax capping. I think it's realistic and fairly on the moderate side of things.

Frankly, I am a bit disheartened because the bill seems to be losing the whole point of meaningful reform, at least in my definition of "meaningful" - which in my ideal world - means cost-control and realistically financed universal access if not coverage. After reading about the Healthy SF fact sheet today, the plan seemed promising. A group of friends were at Cha Cha Cha (tapas bar with awesome sangria and mojito by the way) in SF last Friday, and one of us pointed out that there was actually a line item for Healthy SF on our $100 bill (fyi, there was about 6 of us and we were hungry and had alcohol) for a mere $2.50. Seriously, that's like 1/50th of the total cost which is pretty much nothing! I'd be curious about whether or not SF does report healthier outcomes and I'd be curious as to how they'd measure that and determine that but it seems to be working well.

I am completely perplexed frankly by all this. We expect so much but we are unwilling to pay for anything or assume any responsibility; but when we don't get it and all hell breaks loose, we look to other people (i.e. gov't) and say "Well, why aren't you doing anything???" I guess this goes back to the fundamental values of our society in general I guess. Are we seriously that fickle??? I think I may have just posed a rhetorical question.

All disclaimer out there, I'm a self-professed Obama fan, and completely admire the guy for taking on this job amidst all the madness right now. It doesn't mean I agree with everything he's doing but in my opinion, he deserves the Nobel Peace Prize for just maintaining some sort of peace and order in trying to pass health care reform. On the global level, I'm not so sure and even if you disagree- just be happy for the guy for the sake of being happy for someone who got an award. Ok I know it's trivial and a bit like comparing apples to oranges, but we were generally happy for Taylor Swift when she won the VMA even though many people didn't think she deserved it and that Beyonce has done so much more, why can't we be happy for the President we voted into office for winning the Peace prize? Yes, I digree I know...but disagree with me by all means!

Big Food vs. Big Insurance

Not sure if this article has been mentioned in the past (as, you know, "Today in the New York Times..." seems to be something we say in every class), but the NYT published this on September 9, 2009 about how all this talk about health care reform has not touched on the fundamental question of food reform in the U.S.

In this article, the authors bring up that fact that "we’re spending $147 billion to treat obesity, $116 billion to treat diabetes, and hundreds of billions more to treat cardiovascular disease and the many types of cancer that have been linked to the so-called Western diet.One recent study estimated that 30 percent of the increase in health care spending over the past 20 years could be attributed to the soaring rate of obesity, a condition that now accounts for nearly a tenth of all spending on health care."

A significant amount of healthcare money is being spent on chronic conditions. So, it seems that it would make sense that saving costs on health care expenditures starts more upstream than treating people after they develop diabetes. But whether because tackling the entire food industry is too daunting or whether it's just not a priority to the current Administration, I feel that this factor on the American population's health can not be ignored.

There has been some discussion on the soda tax, but other methods of improving the American diet include diversifying the regional food economy and making school lunches healthier and from regional growers instead of far-away food manufacturers.

Anyway, I'm going to conclude with (1) the link to the article:

http://www.nytimes.com/2009/09/10/opinion/10pollan.html?pagewanted=1&_r=1

and (2) a quote from a very frustrated Dr. Cox (to an overweight CHD patient) from the NBC show "Scrubs" which pertains to food and health. "Guess what, you are what you eat, and clearly you've gone out and eaten a big fat man."

Pay for Performance

Hey guys,
Just to follow-up on our discussion on Pay for Performance issues in class this afternoon...a friend in the MBA-MPH program worked a lot with P4P in SoCal before coming to Berkeley, and found that unfortunately it's got a lot of kinks that still need to be worked out (as we talked about today.) He sent me this video; it's pretty interesting what studies have found on how people's problem-solving methodologies change the second you give them some sort of consequence/goal/penalty/incentive riding on the outcome of their decisions. This video talks about the psychology of problem-solving in general, not specifically how it relates to physicians, but my friend said that he saw the application of this concept when he was working with the docs on the P4P initiative. The video's a little long, but you get the main points from the first 5-10 minutes :-)

-nina

http://www.youtube.com/watch?v=rrkrvAUbU9Y

Drivers of Health Care Spending

Hi All,

Just wanted to share with you the CBO report that shows the primary drivers of health care costs:

http://www.cbo.gov/ftpdocs/89xx/doc8947/01-31-TechHealth.pdf

You'll notice that defensive medicine ranks low on this list... at the same time you'll notice that the parameters assessed vary widely in their overall impact among the three studies....

Senate Finance Committee Approves Baucus Bill

As you probably know by now, today the Senate Finance Committee approved Max Baucus' health care reform proposal on a 14-9 vote. Not only is this a big deal for being the last version of the health care proposal bill to get out of a committee, but this event is also generating quite a stir because of Republican Olympia Snowe's decision to break from party lines and vote with the 13 Democrats.

http://www.nytimes.com/2009/10/14/health/policy/14health.html?ref=us

Also on the NYT website is a small collection of blog entries from scholarly contributors about today's event (http://roomfordebate.blogs.nytimes.com/2009/10/13/why-one-vote-matters-in-the-senate/). Some of the interesting points that I found include:

1. The very fact that we're making such a big deal of one Senator not voting with her party demonstrates the hyper-partisan political environment that exists at the moment. Is it a necessarily bad thing that no other Republicans have signed on to this bill, or is it just a normal part of legislating big issues?

2. How long will Olympia Snowe continue to vote with the Democrats? Will she be willing to support a public option? If so, with what conditions?

3. Can Congresswoman Snowe's vote encourage other Republicans to vote with the Democrats? Maine seems to be an interesting case, though Senator Snowe is a Republican, the state itself is regarded by many as an "independent" (words of Larry Sabato). Therefore it is not surprising to see the representatives from Maine "stray [from party lines] with some frequency." It could be argued that Snowe represents voting for what her constituents wants versus what her party wants.

Information-rich environments....and calorie-rich burgers

This article:

http://www.nytimes.com/2009/10/06/nyregion/06calories.html?_r=1&ref=nyregion

is about the new New York City law that restaurants must prominently display the calorie counts of all items. A study analyzed people's receipts and found that the law had no effect on calorie consumption in low-income neighborhoods. However, people have said in surveys that they believe the extra information has made a difference in their eating patterns.

Proponents of choice in the health-care sector believe that consumers will make good decisions as long as information is available to them. In this particular case, that doesn't seem to be true. Too bad it didn't work, since this is an intervention that costs very little, and reaches every person that walks into a restaurant.

Hi Everyone-

I saw this interesting article in the NYT this morning. While there are way, WAY more issues at play than just costs (religion, morals, reproductive choice, etc), I was struck by the fact that, at least in individual anecdotes, that insurance companies end up spending much more money caring for the often premature babies born as multiples from intrauterine insemination, rather than paying for the more expensive IVF treatments up front. This touches on a few of the different themes we've discussed in class:

-I know that this is not at all a case where we would say that IVF is a "preventive" measure, but it does raise questions about investing dollars upstream rather than downstream.
-This raises some issues about cost-effectiveness research, and how it relates to patient demand. If couples were to be given cost-effectiveness data on the different fertility treatments, do you think demand for any of these types of treatments would go down?
-What about the idea of including pain and suffering estimations in cost-effectiveness research? Here comes controversy! I don't think Americans would ever accept being told you could put a "price on life," or that we would ever be comfortable with some research board deciding the monetary value of a life that is going under extensive medical treatments. Just look at how much we value keeping an elderly person alive for a few days, even if she is barely conscious and hooked up to tubes in the ICU.

I know that fertility treatments and reproductive choice are a controversial issue...just want to see what others out there might be thinking.

AHIP assails health care legislation

Here's a good follow up to my group's presentation on private financers last Wednesday. America's Health Insurance Plans (AHIP) has taken a strong stance against health care legislation drafted by Senate Democrats. The organization states that the legislation will drive up premiums and the cost of coverage for a family, as well as encourage people to defer buying insurance until they are sick.

Enjoy:

http://www.nytimes.com/2009/10/12/health/policy/12insure.html?_r=1&hpw

Would you have faith in a system that looked like this?

This was a rather comical organizational chart that I ran across on a congressman's website. While pretty ridiculous, it is worth a laugh. This is apparently being circulated among Republican congressional leadership as a visual representation of what those Democrats are up to in their government takeover plans.

Enjoy: http://fleming.house.gov/uploads/Org%20Chart%20of%20Dem%20Health%20Plan.pdf

The Decline of The Professional??

In reference to our discussion on Wednesday (10/07) about the changing dynamics of the health care profession, here is the NY Time's article discussing the changing public opinion of The Professional that has possibly contributed to those dynamics.

http://www.nytimes.com/2008/01/06/fashion/06professions.html?scp=4&sq=Profession&st=nyt

One particular paragraph sums up one opinion on the shift: "This decline, Mr. Florida argued, is rooted in a broader shift in definitions of success, essentially, a realignment of the pillars. Especially among young people, professional status is now inextricably linked to ideas of flexibility and creativity, concepts alien to seemingly everyone but art students even a generation ago." If definition of success is the ability to be flexible and creative, then I think that the Professional can still be viewed as an icon of success - it takes more than an understanding of physiology to be a good medical practitioner, in fact, I've heard medicine referred to as an art form as much as it is referred to as a science. That being said, maybe it's not only a shift in the ideals of success that have led to a decline of The Professional....

Thoughts?

CBO and the Healthcare Plan

I found this to be an interesting contemporary article regarding the use of policy analysis. We don't hear about the Congressional Budget Office (CBO) very much in the news, or in our day to day lives, but when they give support to a bill, or champion a legislators belief or value system, it is touted as a triumph.

If the CBO found that the plan would not have decreased the deficit, or if it was found to increase the deficit slightly with the same coverage estimates, do you think it would be a NYT newsworthy article? Do you think it would still be championed by the Dems,? Do you think it would actually have any impact on legislative process or decision-making regarding the Baucus Plan itself?

http://www.nytimes.com/2009/10/08/health/policy/08health.html?_r=1

NPR Series called "Health Care: Are You Covered?"

Here is a shout out to all you NPR fans out there!
I was listening to NPR yesterday morning and heard another story from their series called "Health Care: Are You Covered?"
I have realized over the past few weeks that I have been listening to these stories with great interest, so I wanted to share them.

The series is a set of personal stories from people all over the US about how they pay for health care costs for themselves and their families. It covers stories of people from the uninsured to people who have the best coverage one could ask for.
This website is where you can go to just listen to a few people and read their stories:
http://www.npr.org/templates/story/story.php?storyId=112867626

I think something like this is a good way of getting people's personal stories out there, for others to relate to and learn from. Let me know what you think!

Eveeryone in the US has been looking for new models of health care systems for a long time. Journalists alternately cling to and tear apart systems in various countries while academics and analysts write whole tomes trying to draw lessons applicable to the USA. Just when it seemed we'd run out of countries (Britain, Canada and France are such old news, and Cuba's politically off-limits), Switzerland started getting more attention.

On Sept 30th the NY Times ran an article about the benefits of the Swiss health care system and how perhaps they could provide answers to the US (http://www.nytimes.com/2009/10/01/health/policy/01swiss.html?_r=1&ref=health). Other news agencies have been and are running similar stories (Here's NPR's from July 08). The gist of the argument is that the Swiss are managing to insure the entire population using only private insurance companies. Competition is maintained, coverage is mandatory and everything runs more or less smoothly, or so it seems. The NY Times quotes Regina Herzlinger, Harvard Business School professor, as saying, “What I like about it is that it’s got universal coverage, it’s customer driven, and there are no intermediaries shopping on people’s behalf. And there’s no waiting lists or rationing.” Outcomes are quite good, with a high life expectancy (79/84 m/f - http://www.who.int/countries/che/en/) and overall satisfaction with the system is good, but how much of a utopia is it really? Some news articles touched on the ideas of high costs...both overall (While it's no USA, Switzerland's health care still costs 11% of GDP) and individually. Premiums are paid mostly by individuals and are regressive, though the government does step in to help the 35-40% of households paying more than 8% of their income to premiums. (NYTimes) Cost-sharing (copays etc) are also higher in Switzerland than other countries. But for all that, it might be worth it if the system works?

The thing is, it's not working. At least not perfectly. The Neue Zurcher Zeitung, one of Switzerland's main newspapers, ran this article today with the headline "Health Insurers have too little reserve; Premiums of 18 funds could increase in the summer." The article talks about how the private insurance companies are struggling and how at least 18 of them will most likely raise their (already very high) premiums within the next year or risk folding completely. It looks as though even this country, then, is not as much of a model as we'd hoped.

Flying Doctors

This time around I thought I'd write about an incredible federally-funded program I learned about in Australia called the Royal Flying Doctors Service. The Service provides aero-medical emergency and primary care assistance to Australians living, and traveling, in the remote lands of the outback, many of whom make emergency calls from satellite radios provided by the Flying Doctors Service. They fly to over 660 patients per day and span an area equal in size to Western Europe.

One of the most impressive features of the Service is its focus on preventative services. Doctors, flight nurses, and other practitioners staff over 30 clinics spanning remote Australia (several thousand kilometers) offering vaccinations, checkups, and dental exams. They also provide radio or telephone consultative services 24 hours a day, which are available for emergency or routine health concerns. One of my favorite components of the program is that they extensively provide 3500 "medical chests" to isolated properties, indigenous communities, cattle stations, etc. These chests contain numerous drugs and supplies with which patients can treat themselves with telephone assistance from a nurse or doctor. They even hold regular field days to educate children and adults on how to incorporate health promotion in their everyday lives.

I toured their Central Operations office while in central Australia and it's like a well oiled machine. Their quality metrics are excellent and they have an impressive safety record. I wonder if we can use some of the values and goals of the Royal Flying Doctors Service in some of our domestic health policy considerations. We may not need airplanes to reach our remote, immigrant, or less educated populations, but I think we can learn a lot.

If you want to read about this some more, here is the site - www.flyingdoctor.net

Making prescription drugs more affordable, or sneaky marketing tactic?

A recent article in the Wall Street Journal discussed how “a growing number of dug makers are offering [discount and rebate] coupons that help reduce out-of-pocket costs of some prescription drugs.” According to the article, the coupons are mostly for newer brand-name drugs, and they can lower or even eliminate co-pays for the drugs, depending on the insurance plan.

On the consumer advocates side, the argument is that these coupons help patients save both on drugs they are already using and on new therapies that the patients may want to try. Essentially, they view these coupons as “co-pay assistance.” The other side argues that these coupons may undercut insurers’ cost-control measures, because they may steer consumers towards brand-name medicines that aren’t on the preferred list of pharmacy-benefit plans with tiered formularies. While a coupon could eliminate the patient’s co-pay for a new, brand-name drug, the insurer still has to pay the negotiated wholesale price. This means that there is the potential that use of these coupons could “lead to higher premiums in the long run.”

Here’s the link to the article…
http://online.wsj.com/article/SB125339394529025429.html

It was bound to happen

The health care debate has come around to abortion politics. As this article in the NY Times explains, anti-choice groups are pressuring Congress to prevent consumers who receive federal subsidies from purchasing coverage from health plans that currently cover abortion.

Their claim is that consumers who purchase these insurers' health plans could potentially use those federal dollars to access abortion care. Public funding for abortion was banned, with limited exceptions, under the Hyde Amendment of 1977, which is part of Medicaid law.

This has the potential to pressure private insurers to remove abortion care from their list of covered medical procedures in order to allow consumers who receive federal dollars as part of the health care reform proposal access to coverage. As the frantic action alert I received from Planned Parenthood today succinctly states:
if [this effort is] successful, access to abortion will be practically eliminated in health care reform. And without access, there is no choice.

Whatever your personal politics, it is a remarkable thing when a small but vocal minority can hijack a national issue so effectively and with such sweeping implications. In this case, those who could be hurt include not only insured women who need access to safe and legal abortion care but uninsured women who are just trying to get comprehensive health coverage.

Goodbye Public Option

Yes it was expected, but it is still sad to see that although 2/3 of Americans approve of the public option (CBS poll 9/24), it was voted down by 2/3 of the Senate Finance Committee. Although there were various reasons each senator gave for their nay vote, I found Senator Max Baucus’ reasoning most intriguing, “My first job is to get this bill across the finish line…No one shows me how to get to 60 votes with a public option". I think we all agree that something is better than nothing, but how much compromise must take place before a much-needed big shift is watered down to something that resembles yet another increment? In this case though, I am confident that whatever happens will be more than just an increment in policy change, but one has to wonder how much is enough when it comes to gutting up good policy in the name of passable policy. Furthermore, I have to say that this whole business about a real Democratic filibuster-proof majority is just an illusion, overblown by party members as well as the media. There was so much hype when Al Franken was made the 60th Senator, but what has really come of that? One thing that the federal government truly needs to learn from successful is the notion of under-promising but over-delivering. Government seems to do just the opposite (remember FEMA, No Child Left Behind, “mission accomplished") but I suppose that’s what happens when you want to make your electorate happy and get elected to office. Not to sound facetious, but I hope that those who are against or voted against the public option, or any of the reform efforts live long and prosperous lives…long enough to witness a true reformation of healthcare in the future. Imagine that!

faith as the solution to health care costs?

I watched this really interesting 3 minute clip on ABC's World News today about an alternative to traditional health care insurance...faith. While I was quick to scoff when I heard the title of the segment, "Faith-based Health Care for Evangelicals," by the end I was surprised how simple and apparently effective this is.

How it works:
There are three Christian health plans in the US, where members cover each others' major medical bills. To be a part of these health plans, one must be a church-going Christian and agree not to smoke, drink heavily, or have extramarital sex. Families pay $285/month to these faith-based health plans like Samaritan Ministries, which in turn distributes the money out to members who have medical bills that month.

The video made sure to point out what the critics are saying, things like...since it is not technically insurance, it is not regulated by the government and there is therefore no guarantee that medical bills will be paid. Even though there is no guarantee that everyone's bills will be paid, Samaritan Ministries says that they have never failed to cover a member's medical bills in their 15 years of existence. That's more than can be said about a lot of other insurance companies...

After watching this I still have a lot of questions, like about how this health plan deals with preventative care or ensuring that their members adhere to the requirements (namely, going to church and staying faithful in marriage). But nevertheless, it appears to be a cheaper alternative that is working for tens of thousands of Americans.

Here's the link to the video and article:
http://abcnews.go.com/Health/faith-based-health-care-evangelical-christians/story?id=8696127

Here's an article in the New York Times trying to dispel some public fear about the H1N1 flu vaccine (and, really, vaccines in general). Their main point is essentially that negative health events happen all the time, and just because one of those occurs after getting the vaccine does not mean it's linked. (They also talk a bit about the swine flu vaccine disaster of 1976 - for those of us reading The Swine Flu Affair it's an interesting perspective) The Associated Press published a similar story, also explaining that not all adverse health events are linked to the vaccine just because they occur shortly after, and also spending more time detailing government tracking. Finally, ABC and other news agencies are playing up the fact that "swine flu causes heart attacks but vaccine protects." Normally the press tends to be the fear-mongers and nay-sayers (negative news gets more of an audience than positive), but now they are taking a larger role in dispelling rumors and convincing people to get the vaccine. It will be interesting to see how the swine flu vaccine plays out this time around, and how the press continues to react.

Health Insurers' Income Statements!

Yayy, numbers! Well, not exactly (if you don't want to see them but want some qualitative idea of what they are). But I found it really helpful to get an idea of what kind of profits insurance companies are looking at. Surprisingly, it's not that much percentage-wise. I honestly thought that they were making a much larger profit margin.

http://blogs.wsj.com/health/2009/09/25/unpacking-a-big-health-insurers-income-statement/
(or see below)

--

By Jacob Goldstein

In a year when everybody’s talking in sweeping, vague terms about health costs and the insurance industry, it’s useful to pause and dig into some really specific numbers to better understand how the money flows.

That’s what Princeton health economist Uwe Reinhardt does today, dissecting an income statement from the health insurer WellPoint in a guest post over at the New York Times blog Economix. Here are a few of the figures.

In 2008, the company’s total revenue was over $60 billion, more than 93% of which came from insurance premiums. About 6% came from fees for administering insurance for self-insured companies, and 1% came from the float.

WellPoint paid out about 84% of the premium revenues it collected to pay for health care and drugs for the people the company insures. That percentage is known as the medical loss ratio or the health benefit ratio.

The company spent roughly $9 billion, or 14% of total revenue, on marketing and administrative expenses.

The company’s net income was $2.5 billion, which means its profit margin was 4%. Profits were just over 5% of total assets deployed by the company, and 11.6% of the equity shareholders had in Wellpoint. “Relative to other industries, these are not particularly high numbers, nor are they particularly low,” Reinhart writes.

He notes that marketing and administrative expenses “typically are a far bigger enchilada” than profits for insurers. “It is here that the health insurance industry is being challenged to search for economies.”

--

Blogs and more blogs

Hi Everyone-

Sorry if you have already gotten an email blast about this, but I wanted to let you know about some other health policy blogging going on...PolicyMatters, the journal of the policy school, has a blog as well, and if you scroll about halfway down, you can see some entries about health care, for your reading pleasure.

http://policymatters.net/

Also, on the lighter side of the things, check out how celebrities are doing their part to make sure we remember who the real victims of health reform are:

http://www.funnyordie.com/videos/041b5acaf5/protect-insurance-companies-psa

PBS special - TONIGHT, 9/24!!!!!

PBS is airing a special 90-minute program on health care reform. NOW, Tavis Smiley, and Nightly Business Report are all contributors to the program. Not to be missed!

http://www.pbs.org/now/shows/health-care-reform/index.html

Obama on Letterman and Healthcare Reform

Check out Obama on Letterman talking healthcare reform. The health care reform talk is near the end and includes Obama's take on racism as a main cause of all the dissent, anger and town hall madness or even the most Rep. Joe Wilson behavior during his address.

I find it interesting and frankly, quite striking, that Obama is using popular media like the media to advocate for health care reform. That's meant to be a good comment by the way. Talk about getting out there and promoting the cause. I guess in terms of convincing people, you gotta give the guy credit for taking the road less travelled. I think this goes back to some of the comments that were brought up at the health care reform workshop and in some ways points back to the idea in policy that the President has a national constituency and in that sense has a unique leverage.

I don't necessarily know if Letterman's audience are in some ways biased or if Letterman himself is biased, it is New York afterall and maybe the optimist in me would still like to believe that using this new form of advocacy by the President would reach a wider audience. In 200c, Oprah was noted to be one of the most effective health educators around.

In that case, Mr. President, has your staff been talking with Oprah's people? After all, she does have a new season and most likely a new couch.

"My question, then, is what you all think about whether people can really be convinced either that things aren't as great as they seem, or that what they think they like really won't change. Or is it even necessary to convince people of either?"

Hmmm - Andrea, convincing people is always so difficult. If it were to happen, I feel like this is an instance where we need to somehow get the little penguins to join together to tell their parents that they should buy into this. Maybe Obama should start a nationwide college tour to build momentum/support and show people that there are supporters out there. It's great trying to bring everyone together, but I think that when you hold multiple town halls/joint sessions of congress (okay, so maybe that couldn't be helped :P ) where there are loud, angry dissenters, supporters might begin to feel as if they're on the fringe.

for your health...and your entertainment?

While flipping through the channels earlier tonight, I was taken by surprise when the face of none other than Professor Art Reingold appeared on the TV screen. It was the CBS5 news, and he was addressing...you probably guessed it...swine flu. In an example of true public health epidemiology, he was making an announcement to the public that, contrary to common belief, hand washing is not enough to protect you from the swine flu, or any flu for that matter.

Since stopping breathing isn't really an option...time to get vaccinated? Tang Center's flu shot schedule: (http://www.uhs.berkeley.edu/home/news/pdf/FluShotFlier09.pdf)

You can read the article and watch his interview here:
http://cbs5.com/health/hand.washing.h1n1.2.1194097.html

Most insured Americans at least say they're happy

I just came across this study by the Kaiser family foundation that found that, of all insured Americans, the majority say they are happy with their plan. Deeper digging revealed that different groups of people, including those in lower socioeconomic groups, were not so pleased. Furthermore, more questions showed that even those people who said they were pleased with their plans really did have quite a few gripes. I think this data gets at part of the challenge of convincing US citizens that health reform is necessary. Most of the time, people will be relatively happy with the status quo. In many cases, if people are the ones who have chosen the status quo (i.e. people feel as though they're choosing their health insurance), they're even more likely to say they're happy with it, if only to justify their choice. When you start asking more questions, you may find, as this study did, that people are unhappy with most aspects of something, but they're still, overall, going to be convinced they mostly like it, if only because it's familiar and they know they don't hate it. If the majority of Americans are insured (which they are), and if the majority of the uninsured claim to like their insurance provider (which this study claims), and if many people believe that the public option (or, more broadly, health care reform of any sort) will change their insurance (which people do), then it will be very hard to convince people to change. By that logic, there are 2 options: convince people that all those things they said they didn't like about their insurance are actually large enough problems for them to admit they're dissatisfied overall with their insurance, or convince them that the public option won't affect their own choices. Obama has clearly been trying to do the latter in his speeches, and the former seems time-consuming and complicated (pointing out the faults of these enormous insurance companies will not be a politically-popular move). My question, then, is what you all think about whether people can really be convinced either that things aren't as great as they seem, or that what they think they like really won't change. Or is it even necessary to convince people of either?

Special Interest Groups: What's their role in the reform?

Hey guys.

I'm going to respond to Patrick's post, and then pose a couple (somewhat-rhetorical) questions. I found it very interesting that while the AMA's position is one against the public option, the majority of physicians belonging to AMA are in favor of the public option, in some shape or form. Off the bat, I just have to throw the fact out there that the majority of physicians sign up for the AMA because it's "what you do", you get your little purple ID card, keep it in your wallet (or the back of your desk drawer), and conspicuously arrange your free subscription to JAMA on your desk as to assure your patients will see it. Somewhat of a cynical exagerration, but you catch my drift. That being said, I guess it's not too hard to conceptualize how the majority of the group's members feel one way, yet the official position of the group fails to reflect the majority vote. The average doc out there, "working 75+ hours per week, trying to please a million masters, attempting to keep his head above water in the sharktank" is about as invested in the AMA as schoolchildren are in classwork on the day before Christmas vacation. In fact, this lack of leadership and interest has been a topic of concern for the AMA for decades. And it's sad, because as much as the reform (in whatever form it eventually takes) is going to effect patients, insurers, etc...it's going to rock the worlds of physicians.

As Patrick mentioned, the medical community is widely split on the reform issues. So much so, in fact, medical schools host debates (tactfully-advertised around campus as "expert panel discussions on health reform") between physicians from the two camps: mainly the AMA and PNHP (Physicians for a National Health Plan.) Med students pile into auditoriums to listen to middle-aged docs battle it out over reimbursement, treatment of the uninsured, and how there are more billers in their office than physicians due to the headaches involved with billing several different insurance companies. In general, primary care physicians side with PNHP, and specialists side with AMA--but this is a gross overgeneralization (as the statistics in Pat's article illustrate.) I guess I'm having a hard time reconciling how the AMA, whose vision is to "help doctors help patients by uniting physicians nationwide to work on the most important professional and public health issues", can publicly take a stance on such a massive issue as national reform, with an opinion that does such a mediocre job of capturing the best interests and feelings of so many (the majority!) of its constituents. Sure, there will always be a few dissidents in every interest group...but this is more than that. In this case, with so much on the line, and such a massive discrepancy of opinion amongst its constituents, is the AMA justified in publishing any official stance on health reform? That's what an "interest group" is supposed to do, right? Attempt to influence policy, in some way, by at least taking some official stance on the issue. Or is this a classic example of the squeaky wheel speaking inappropriately on behalf of the silent majority?

New survey in NEJM finds that, overall, doctors support a public option

Hi all,

I found this interesting article published by NPR in my daily read. In it, the authors describe that physicians as group have traditionally had difficulties giving an official stand on health care reform. As a medical student, I can definitely see this as being true. From my personal experience, doctors in primary care tend to prefer a public option and those in high-paying specialties tend to be content with the status quo. However, in this article, a recently published survey in the New England Journal of Medicine has found that 63% of doctors favor a mixed system that includes both private and public insurance; an additional 10% favor a single-payer only system. When the public was polled, about 50-70% said that they are in favor of a public option.

What else is interesting is that the majority of the doctors who are members of the American Medical Association (AMA) are in favor of a public option, though the organization itself is opposed to it. The AMA has historically been opposed to health care reform as one of its main objectives is to protect the interests of physicians, not improving patient access or care. Also, I've heard that the AMA only represents about 20% of physicians; in the NPR article, the authors state that less than one-third of physicians belong to the AMA. Most physicians join their own specialty groups. If this is true, then here we have a very powerful lobbying group against a public option who does not actually represent the opinions of its constituents.

Instead of looking to the AMA as the voice of physicians, one can find differing opinions from other medical groups. The American Medical Student Association (AMSA) represents the future physicians of America and has a very firm commitment to universal health care and enstating a single-payer system. However, not every medical student is involved with AMSA.

Just the other day, massive protests against federal spending took place in Washington DC. Given this NPR article stating that the majority of both doctors and the general population actually favor a public option, one has to wonder who exactly these protesters are. Are they simply the loud minority? How do these statistics fit in with what we discussed in class -- that most Americans are happy with their own health coverage?

I have included both the NPR and NEJM articles below:

http://www.npr.org/templates/story/story.php?storyId=112818960

http://healthcarereform.nejm.org/?p=1790&query=home

Let's discuss!

"Socialized Medicine"

Hey everyone, I thought this would be a great article to share:

http://www.nytimes.com/2009/09/03/opinion/03kristof.html?_r=1&em

Here's a small excerpt:

"Until the mid-19th century, firefighting was left mostly to a mishmash of volunteer crews and private fire insurance companies. In New York City, according to accounts in The New York Times in the 1850s and 1860s, firefighting often descended into chaos, with drunkenness and looting. So almost every country moved to what today’s health insurance lobbyists might label “socialized firefighting.” In effect, we have a single-payer system of public fire departments.

Throughout the industrialized world, there are a handful of these areas where governments fill needs better than free markets: fire protection, police work, education, postal service, libraries, health care. The United States goes along with this international trend in every area but one: health care."

The article also discussed how the government run health care systems (VA, Medicare) are what people actually like, has better performance and is cost-efficient. I just find it intriguing that other systems in America--like fire-fighting--are okay to be set up with a single-payer system but health care is constantly faced with extreme opposition and fear of reform. Granted, health care is a different area, even creating/proposing small incremental changes exerts a lot of effort and time. Maybe, like this article points out, when put into the context of looking at the spectrum of activities/positions in the US that are so-called "socialized" people can begin to understand the positive implications the single payer system or public option could potentially have. What do you think?

End of life care needs more attention

I mentioned these videos in class and I highly recommend you watch the eye-opening 15 minute talk by Dr. Diane Meier on long term care (just scroll to the bottom): http://www.healthaffairs.org/issue_briefings/2009_08_20_fact_vs_fiction/2009_08_20_fact_vs_fiction.php

I worked with Dr. Meier at Mount Sinai Medical Center and she is such a ground breaker in Palliative Care advancement. She is the director of the Center to Advance Palliative Care at Sinai and is a Geriatrician/Palliative Care physician, but she is planning to take a 1 year leave to move to DC and work on healthcare reform.

If you follow the topic, her name will continue to appear like in her recent Newsweek article on the Death Panel controversy. In her powerful healthaffairs.org speech, she talks about 2 patients at the end of their lives, each of whom have VERY different experiences. If we want to control costs, this issue urgently needs to be pushed to the forefront of the political discussion. The way we treat very sick and very elderly patients sometimes defies all reason and I have always wondered why. Is it the way we educate medical students? Is it our pervasive fear of death? Demands from patients and families? Is it all about money and physician incentives?

"Did you hear the one about..."

... The woman whose kidney surgery had to be redone after Medicare stopped paying for her anti-rejection drugs? Just ran in the Times:

http://www.nytimes.com/2009/09/14/health/policy/14kidney.html?ref=health

Yes, it's another potentially incendiary story that will inevitably be mentioned in one of Obama's upcoming speeches, but it's also an example of potential good will that doesn't go far enough, often out of necessity.

"The rationale for leaving out younger transplant recipients was simply that the money was not there, Congressional aides said." Not to be nihilistic, but it's useful to remember that policies put forth with the best of intentions can fall short, independent of our tireless efforts; but it's no reason to stop trying.

Medical Ethics during Hurricane Katrina

Hey Everyone,

I read this article in the New York Times Magazine a few weeks ago, and found it really interesting. The article tells the story of a for-profit hospital in New Orleans during Hurricane Katrina and the difficult decisions its physicians faced in deciding how to evacuate its patients during the storm. Some of the physicians have been accused of hastening the deaths of some terminally ill patients by delivering lethal injections of medications to those they deemed not able to survive the storm. I am looking forward to hearing everyone's perspectives on the article:

http://www.nytimes.com/2009/08/30/magazine/30doctors.html

Doug

Redefining the level of Health Care Competition

If there was one defining article I read that convinced me that I needed to go back to graduate school to learn more about how to change a non-system, this was it.

Porter, M. & Tiesberg, E.O. "Redefining Competition in Health Care". Harvard Business Review. June 2007

http://ucelinks.cdlib.org:8888/sfx_local?genre=article&issn=00178012&title=Harvard+Business+Review&volume=82&issue=6&date=20040601&atitle=Redefining+Competition+in+Health+Care.&spage=64&sid=EBSCO:bth&pid=

HBS Professor Michael Porter and Darden School Professor Elizabeth Olmstead Tiesberg discuss the various stakeholders in the health care system and how each can potentially undergo a transformational change to improve the quality and outcomes of the US health care system.

If you find this article enlightening, I HIGHLY recommend reading their book, "Redefining Health Care" (2007). It is by far one of the best books I have read on innovation in health care.

If you have read the article or the book, do you agree with their suggestions? Are some of their suggestions too radical (not as in right-wing but as in idealistic)? Which ones are the most feasible?

Let's discuss!

Healthcare Reform, Illustrated

For those who - like me - feel embarrassingly uninformed about the details of healthcare reform, I thought I'd pass along this set of "napkins" illustrating the main points of the debate. I can't vouch for the presence/lack of bias, but it helped clarify some things for me. Also, there are pictures!

Click here for the full slideshow.

"Meaningful" Reform?

I enjoyed the discussion at the HPM workshop this afternoon, but I think one point that was glossed over was the idea of "meaningful" reform. For the sake of argument, let's suppose that Professor Robinson's predictions come true: Obama signs a bill in the next few months that includes an individual mandate, no public option, some malpractice reform, etc. But none of these components - and really none of the discussion that I've seen of health reform so far - have given any real evidence of containing costs.

I certainly think it would be an accomplishment to pass a plan that makes a dent in the huge number of uninsured, but covering more people isn't necessarily going to contain costs. I understand the argument that with more people, particularly young healthy people, in the insurance pool paying premiums the costs per patient may go down slightly, but I don't see how this could cap any skyrocketing costs due to technological advances and expensive pharmaceuticals, for one. So my question is: can we call a plan without any real cost-containing measures "meaningful" health reform?

Welcome to Fall 09 HPM Class

Hi everyone - welcome to the Foundations class blog. I hope you find it a vibrant place to post, comment, share, discuss over the semester. Lots to talk about! Hope you are all planning to watch the President's speech tonight and I expect a firestorm of blogging as a result!

Kim