Monday, January 30, 2006

My Pre-Emptive Response to BUSH Health Proposals

I recognize fully the arrogance of responding to a speech that hasn't been given. But our times call for boldness. So I decided to be bold. Our US Health Care System is in rapid real-time meltdown which was the reason why Cervantes and I created this blog.

Tommorrow night our President will spend considerable time during his State of the Union Address (SOTUA) on his and Dr. Frist's Health Care Initiatives. He will not be bold. He will extol the virtues of what he calls a "consumer based approach to health care emphasizing tax incentives". I promise you these approaches are destined to fail. "We the People" will continue to pay more for health care and get less than any other western nation peer country. Mr. Bush and Dr. Frist's health care policies and proposals, like other aspects of his ownership society programs, will benefit the rich. The poor as Cervantes says will be "owned"in this ownership society. Below is my #8 point health care "plan" I proposed first in 1995. I have revised it almost ten years later for 2006 world.


- Stop prolonging death. It’s both expensive and dehumanizing at best, greedy and cruel at worst.

- Empower US citizens to assume increased individual responsibility for health and convince medical consumers that it is in their best interests not to assume the role of helpless, dependent victims/patients.

- Yet also recognize that we have medicalized America’s social problems. So we must provide healthy and safe jobs for all able citizens thereby reducing poverty and all its subsequent health impacts (possibly 1/3rd of Health Care Costs)

- Provide healthy environments including healthy air, water, soil and food.

- Rebuild America’s public health infrastructure to ensure we provide appropriate macro and individual interventions to especially low income citizens such as childhood and adult immunizations and response to man-made and natural catastrophes.

- Face the reality that a very large percentage of illnesses, injuries and hospitalizations are entirely preventable. Subsequently, the elimination of tobacco, alcohol, drug and medication abuse alone could immediately reduce medical costs by a factor of at least fifty percent.

- Incent and train physicians to maintain the health of patients and populations. Radical changes in provider re-imbursement and medical education strategies are necessary

- Recognize that early childhood preventive medical education can profoundly affect lifelong health behaviors.

proposed by
June, 1995
Revised 2006

Thursday, January 26, 2006

State of Union Speech. Watch your Wallets-Watch your Souls

The President “shall from time to time give to the Congress Information on the State of the Union, and recommend to their Consideration such measures as he shall judge necessary and expedient.” Article II, Section 3, Clause 1. US Constitution

This Tuesday night 31 January 9PM (ET) our President will exercise this option. Early reports indicate our President will address Health Care for Americans which Cervantes and I have addressed on this blog at length. Cervantes and I believe our US Health Care system is in real-time meltdown. The upcoming speech discussions are hard to hear over the din of the triple AAAs of Alito, Abramoff and the Axis of Evil. But the mainstream media and bloggers are beginning to ask what will the President say on Health Care?

Well, if the recently implemented Medicare Drug Benefit debacle hasn't caused our President's speechwriters to workovertime to explain that mess and put forth some bold initiatives, I believe the President is setting himself and Dr. Frist and company up for a big fall. And a feast for smart and bold Dems who REALLY CARE about Health Care for our fellow citizens!

Most importantly- Please tune is but please also-

-Watch your wallets
-Much more importantly -watch your souls

Both are in very grave danger or perhaps "Critical Condition"

Monday, January 23, 2006

Prevention – Let’s Give Ben Franklin A Belated Birthday Present

Founding Father Benjamin Franklin, whose 300 birthday we currently are celebrating, said “An ounce of prevention is worth a pound of cure” (Hmm –was that statistically means tested?). Yet 230 years later America still spends only @2% of its 1.9 trillion dollar Disease Care Industry bill on Prevention. Why in God’s name, I ask, if Father Ben was right so long ago? Let me try to explode (whoops "explore") some myths about Preventive Medicine- a field of medicine that I have attempted to practice my entire 30 year plus medical career. See 5th point on my ETIOLOGY post of 3 Jan

Prevention doesn’t work? - Otherwise highly regarded physicians have tried to convince me for decades that “most of their patients” can’t or won’t change their unhealthy behaviors? Well there is a growing body of scientific evidence that with proper support like health coaches and financial and other incentives people do indeed change unhealthy behaviors from smoking, to diet, to exercise etc. Significant advances in behavioral science like
stages of change
theories and tracking of expenditures made by American citizens - usually out of pocket- on preventative strategies from gym memberships to purchases of vitamins and food supplements is a very real testimony to change capacity.

Prevention doesn’t pay? – Alas- Definitely true in today’s Disease Care system. Incentives for payers rarely exist except at the margins. Assuming you are lucky enough to have health insurance have you ever tried to get reimbursement from your insurance company or payer for wellness programs for example?- Or perhaps for often cheaper and safer alternative medicines?- Or the vitamins and diet supplements you are spending @4 billion dollars a year on? How’ bout getting your doctor to spend time with you to talk about health- Sorry folks-not now- Doctors don’t get paid much for so called cognitive services. Docs have to do something to you in order to get paid like write you a script, order a procedure, or send you to a surgeon. Also the economic returns for the largest purchasers of disease care-namely corporations and the federal government’s don’t realize fast enough financial returns from prevention to satisfy their constituents like stockholders and powerful lobbyists for the disease care industry who rig the election of our politicians. Finally immoral/amoral anti-prevention health economists argue, even publicly that “we can’t afford prevention” since people might live longer? OUCH! That one always hurt me personally. Well, perhaps we have such a crisis in health care that prevention is now an economic imperative since we as a nation spend almost twice per capita what our major peers/competitors on the global market spend on health care and, to add insult to injury, get less!

Prevention makes patients feel blame, guilt, and/or abandonment? Well- I suppose in part asking patients to take some responsibility for their individual health behaviors is, to some, controversial? After all who wants to grow up? Conversely, however, without decent jobs or decent wages the poor or working poor often turn to unhealthy pleasures to cope with what an unfair society has thrown at them. Also much of prevention is NOT in fact the responsibility of the individual patient. There is institutional prevention such as clean air, water, soil and foods. There is providing all able Americans decent jobs with decent wages. And there are many diseases and conditions that have almost nothing to do with individual health behaviors and choices such as genetic conditions, environmental assaults to our bodies, and acts of fate or god such as natural catastrophes or accidents and crime often leaving little choice or control by its victims. And of course viruses and bacteria are indeed real and are indeed contagious- in some cases highly contagious.

Prevention is anti-technology? Well who ever said that 21st behavioral sciences were not based on technology? It may be different types of technology like sophisticated computer software but it still is nonetheless technology or increasingly sophisticated neuroscience which can unravel for example be the basis for perception, lifelong beliefs and attitudes and other cognitive processes ultimately leading to many health behaviors. And, while we are on the subject of technology, when in April of 2003 the human genome consortium (a private-public partnership) revealed it had unraveled the full sequence of the human genome(30-40 thousand separate human genes) I and others predicted its application to prevention would be far greater than its application to gene therapy misadventures. Now most prominent leaders in medical genetics seem to agree that detecting genetic traits in individuals for let’s say heart disease and cancer holds the best promise of the human genome project. That surely is technology in the service of prevention.

What can we do? In addition to adopting good personal health attitudes and behaviors I strongly recommend that you visit
Health Promotion Advocates
headed by my friend Dr. Michael O’Donnell (PhD) who are making slow yet steady progress on advancing legislation through the US Congress on the value of Health Promotion. You can help! Practicing physicians need to be given economic incentives to help patients change their health behaviors or talk to patients about home life, school or work. Also we all need to become involved in ensuring that much more of our disease care system money is re-allocated to prevention programs. The American Public Health Association has many ways you can become involved in issues on a wide range of prevention topic like childhood nutrition, smoking bans, environmental degradation and many others

Finally a word about my personal views on this topic of Prevention. Prevention and Disease Management (known as tertiary prevention) will no doubt dominate 21st century US Medicine- There simply is no choice on this one. Also, our planet earth is in deep trouble. We are all going down soon if we don’t reverse the poisoning of the bio-sphere to which all human health is inextricably linked. I also personally believe that there is growing evidence that lifelong prevention begins from conception to age 4 or 5. So that is where I would put my health care dollars. I would protect and promote the health of nation’s infants and very young children. That is where real prevention begins and perhaps ends? Feedback very welcome.

The Secret Santa

Once again, sadly, it's subscription only (I almost wrote prescription only), but the new Health Affairs theme issue on hospitals does an excellent job of telling the same important story 8 different ways. I'll depend mostly on Stuart Altman's version since I am a Heller School alum, with an assist from Alan Dobson and colleagues. (Links take you to the abstracts.)

First Dobson. Americans, we are told, don't like to pay taxes, even to pay for stuff they actually need and use. Or at least the people who make the largest campaign contributions make sure they keep their own taxes low. So, one way to keep taxes low is for government to underpay for the stuff it buys. Specifically, in 2002, Medicare payments to hospitals paid 95 cents on the dollar for the cost of hospital services, and Medicaid, on average, paid 92 cents. So-called "free care," schemes by which states reimburse hospitals for care of the uninsured and indigent, paid less than 20% of those costs. Hospitals aren't allowed to print money, so where does all that free money come from? It comes from overcharging private payers, mostly insurers. They paid 122% of the cost of the services they paid for in 2002, and that subsidized Medicare, Medicaid and free care. So one thing that will happen as Congress continues to tighten the screws on Medicare and Medicaid is that hospitals will either have to jack up their prices for private payers, or cut back on services.

Enter Stuart. In the name of spreading freedom and democracy to the United States, we are about to hear in the State of the Union address that we're going to have consumer directed health care. Yes, we've already worked that over pretty well here. But Dr. Altman et al point up another little problem with it. Part of the idea is that hospitals will have to post their prices for everything, and since "consumers" (that what we'll be, instead of patients) will be paying for a big chunk of hospital services out of their own pockets (from big deductibles, co-payments, and whatever is in their finite Health Savings Accounts), they'll presumably go shopping around for the cheapest hospitals.

The classic version of a hospital in the U.S. is a non-profit charitable institution that provides a broad range of services and has a social mission, such that it tries to take care of everybody in need and provide benefits to the community. That's why all that cost-shifting happens in the first place -- it's the only way for hospitals to fulfill their social mission. Otherwise they'd have to refuse all Medicare and Medicaid beneficiaries, and uninsured patients. But there are already growing number of specialty hospitals, usually for-profit, that don't have emergency departments and that only provide particularly profitable services. They'll easily beat out general hospitals for the cherry picked customers in a brave new world of price transparency and comparison shopping by consumers. Meanwhile, in trying to compete with each other, the charitable general hospitals will have to drive down their own prices.

Stuart predicts that the hospital industry could end up like the airline industry -- highly cost-efficient specialty hospitals will drive the classic hospitals into bankruptcy, just as carriers that service limited, highly profitable routes with scanty amenities have sent the big airlines that used to fly everywhere the way of the dinosaur. Write the Brandeis Jeremiahs:

Downsizing, service reduction and salary cuts are not the only eventualities that could occur. It is also likely that the hospital industry could become tiered -- one system with modern up-to-date facilities, some focused and specialized, that serve the privately insured, and one poorer, underfunded and possibly publicly supported system that serves everyone else (Medicare and Medicaid patients, the poor, the uninsured, and many of the chronically ill); one system that dominates suburban areas with high income, high employment, and extensive insurance coverage, and one that serves the inner city, poor rural areas, and retirement communities.

And I'll just add, if those latter constituencies get served at all. Welcome to The Ownership Society, and the Culture of Life, backing into the future, over a cliff.

[Cross-posted at Stayin' Alive.]

Thursday, January 19, 2006

A US Free Market Based Health Care System- Time to Admit This Cruel US Experiment has Abysmally Failed

My 4th cause for our moribund health care system (see once more my January 3 Blog on the etiology of the crisis) was the US’ peculiar obsession with only free markets as the basis for our health care system. In retrospect I was sorry that I used the word “peculiar”- rather I should have used the word “cruel”.

Instead of expounding exhaustively on this topic I believe that what my blog partner and co-editor, Cervantes, posted on this blog on Jan 12 entitled Lost in Space pretty much summarizes my own view. Cervantes wrote this essay a while back with a physician colleague Anthony Schlaff. The basic summary of this essay was that 1) there is no truly free market in health care nor should there be 2) A free market approach to health care blatantly ignores the reality that universal health care coverage serves the public good over the few who are wealthy. (“we don’t trade in human flesh”) 3) The current proposals put forth by the White House and the majority Republican party leaders in Congress are like Health Savings Accounts (HSAs) and free market “competition” approaches to Medicare Benefit expansions (like the new Drug benefit) are real-time failing now or doomed to fail.

There are many fine values-based experts who have written on this topic. Among my favorites is Noam Chomsky perhaps the US’ greatest living intellectual. In a recent interview posted on January 14th of this year on Chomsky in simple language says this “…..say for example health care. Probably the major domestic problem for people. A large majority of the population is in favor of a national health care system of some kind. And that's been true for a long time. But whenever that comes up -- it's occasionally mentioned in the press -- it's called politically impossible, or "lacking political support," which is a way of saying that the insurance industry doesn't want it, the pharmaceutical corporations don't want it, and so on. Okay, so a large majority of the population wants it, but who cares about them? Well, Democrats are the same. Clinton came up with some cockamamie scheme which was so complicated you couldn't figure it out, and it collapsed.” (I, Blake, would add perhaps not as complicated as the recently implemented new Drug benefit under Medicare)
Chomsky goes on to say “Kerry in the last election, the last debate in the election, October 28 I think it was, the debate was supposed to be on domestic issues. And the New York Times had a good report of it the next day. They pointed out, correctly, that Kerry never brought up any possible government involvement in the health system because it "lacks political support." It's their way of saying, and Kerry's way of understanding, that political support means support from the wealthy and the powerful. Well, that doesn't have to be what the Democrats are. You can imagine an opposition party that's based on popular interests and concerns”

Let me recommend another extremely important piece written by Malcolm Gladwell of the New Yorker Magazine on August 29th of this year entitled “The Moral-Hazard Myth- The bad idea behind our failed health-care system”. In this piece, Gladwell explains the concept of moral hazard (an Insurance Industry term) and how this pervasive concept is intellectually and itself morally bankrupt. Critical Care readers –you need to understand this counter-intuitive concept of moral-hazard in order to understand how the Republicans are trying, once more, to redistribute health and wealth to the rich. Gladwell tells us that six-times in the past century, beginning during the First World War, efforts have been made to introduce some kind of universal health insurance and six times we as a nation have failed. Gladwell calls this one of the greatest mysteries of political life in the United States? I attribute it to the immaturity of a 230 year old country which took the good concept of free enterprise in business and made a huge and cruel error of applying it to Health Care which, as Cervantes says, ignores the public good of a healthy US citizenry. We all must act now to stop the very life threatening hemorrhaging of our fatally wounded US Health Care system lest we are forced to administer last rites.

PS- BREAKING NEWS- Upcoming Presidential State of the Union Address will primarily deal with Health Care-

Readers and fellow Americans
- Watch your wallet!
- Watch your souls!

Tuesday, January 17, 2006

Bio-Medical Technology- Label Should Read- “Only Miraculous if Used Properly”

“Symptom” four in my six-point diagnosis of why our US Health Care system is collapsing as put forth on my Jan 3 blog that refers to the
of our Health Care crisis is America’s love affair with technology. Let me begin with an important-very important-disclaimer. I am not nor ever will be an anti-technology Neo-Luddite. Modern bio-medical technology is truly nothing short of miraculous in that suffering is relieved and lives are saved every single day. But as Cervantes, my partner on this blog, has pointed out any technology is simply “tools” and tools alone need humans to be used properly and tools alas are value neutral. Who could possible argue with the benefits of the discovery of penicillin, the smallpox vaccine, the discovery of insulin and the first x-ray and EKG machine just to name a few among hundreds of breakthrough technologies over the past 200 years let’s say. In more recent times one can cite kidney dialysis, in- utero fetal surgery, in vitro fertilization and anti-viral drugs for AIDS patients. Pretty impressive on its merits by anyone’s standards.

Well- here’s the rub. It’s good ole “US of A” excess and greed that causes technology to “bite back” if you will. (Edward Tenner’s phrase in Why Things Bite Back : Technology and the Revenge of Unintended Consequences (Vintage) (1996). Well folks, what do you expect from an adolescent culture that only @ 230 years old? I guess I first learned of the “revenge of technology” (another Tenner Phrase) first from Mary Shelly’s Frankenstein (movie c1931) and Stanley Kubrick’s rogue computer HAL who made a power grab on its human keepers in his movie 2001:A Space Odyssey (c1968) But my real education came in bio-technology from going to medical school in the late 1960’s in Philadelphia. Something didn’t quite compute in my brain as I witnessed the ravages of ghetto life on patients in 95% plus black north Philadelphia only to go home for my evening meal to watch the body count figures from Vietnam coming through the TV. Yet neither of these dominant cultural factors were mentioned by my distinguished and, I’m sure well meaning, Professors of Medicine and Surgery as they spewed forth on the latest technological advances in their give specialties. Hmmmm? I thought “something ain’t right here?” Then a medical student friend of similar cognitive dissonance several years later introduced to Ivan Illich’s groundbreaking work called Limits to Medicine: Medical Nemesis, the Expropriation of Health (1977). Tenner’s book on the revenge of technology which had two chapters on medical technology lead me too Diana Dutton’s book Worse than the Disease : Pitfalls of Medical Progress (1992). These books, in addition to partially validating my sanity in the insane world of US medical education the late 1960s, provided evidence that excess unbridled technology in medicine could and indeed does in fact cause harm. In 1999 I came across a paper in JAMA by Drs Elliot Fisher and H Gilbert Welch from Vermont (Dartmouth and VA Medical Center in White River Junction, VT). In that paper (Avoiding the Unintended consequences of Growth in Medical Care-(JAMA Vol. 282-No 5 Feb 3,1999) these authors put forth the radical proposition that in medicine more might actually be worse? Sounding somewhat similar to part of an oath I took on the first day of medical school written by a guy named Hippocrates that “first I was to do no harm” (actually in oath-“abstain from whatever is harmful or mischievous”) I was intrigued. These two authors put forth the compelling hypothesis that the law of diminishing returns might indeed apply to medical technology and at some point on the medical supply curve additional technology might in fact leads to harm! Ouch! That’s anti-American to believe that technology might not be the only answer to our woes and that the frontiers of bio-medical science might actually reach an l end point.

But we are a can do US culture with infinite limits I thought? Well fast forward the 21st century to the race for new pharmaceuticals that work better and safer than old ones and the hyperbolic promises of the Biotech Industry which, in my humble opinion, provide more very expensive hype than hope. Could it be that “can do” Americans might actually suffer from an excess of hubris? Furthermore, we all know that bio-medical technology ain’t exactly cheap with expenditures attributed to technology accounting for perhaps as much as one-half to two-thirds of cost increases above general inflation of our 1.9 trillion dollar Health Care (whoops Diseases Care) price tag.

Let me provide just one example where biomedical-technology has gone awry. Have you ever had an MRI or Medical Resonance Imaging test for perhaps a pain in your back? (You know that’s the one where you are slid into a hole in a huge clanking noisy metal magnet that surrounds your body) Well if you are an American adult citizen above the age of 40 years of age you are among the thousands perhaps millions who have had an MRI test at 3 to 6 hundred dollars a pop (conventional vs. rapid MRI). That’s a whopping MRI bill we ALL pay for. At a projected $100 billion annually, diagnostic imaging is one of the fastest growing cost areas in American health care. Outpatient imaging procedures increased 44% between 1999 and 2001and spending is expected to continue to grow at an annual rate of 20% or higher.(To get the best numbers for 2004 you have to fork over $7,750 dollars for a well researched marketing report) Maybe you have had several MRIs?. Now mind you MRI technology is good- but it is actually “too good”. In scientific terms this test is too sensitive producing what we call “false positives”. Fully 90% plus of MRIs in patients above the age of 40 have “positive findings” on MRIs and many patients get treated for these findings. Wouldn’t it be cheaper to ask the patient what year they were born and prescribe the same treatments? Or even better to allow for spontaneous healing to occur? My point being this diagnostic technology is diagnosing “getting older” But the diagnosis of “getting older” doesn’t pay much by insurance carriers or other third party reimbursers. So we medicalize the aging process. Many MRI positive patients, especially older back patients go on to have failed surgeries leaving them often more disabled and in more pain than had they been smart enough to not bother to get their MRI in the first place. This is just one instructive example of the how excesses of technology can backfire from health outcomes, human suffering, and economic perspectives. We all bear the dollar and human costs of these diagnostic and therapeutic misadventures. (The truly abusive application of excessive technology applied to the dying deserves a stand alone essay)

In my Holistic Model of Health Care noted in my recent blog on Reductionism I state and deeply believe that a high technology based health care system while not inherently bad is also, to put it simply, incomplete. Integrating the input of competent and values based colleagues from the behavioral and social sciences as well as ethicists, theologians and economists will ensure that our miraculous technology is leveraged to achieve the greatest good for the most US citizens. And that is what I call “Technology Plus” medicine”. This is the medicine we needed yesterday and beginning tomorrow before rigor mortis sets in on our truly moribund disease care system, which by then will surely be too little to late.

Friday, January 13, 2006

Quick update

Thanks to KEO for digging out the link to the historical national health expenditure data at CMS. It's not quite as user-friendly as the subscription only Health Affairs article because it doesn't come with much interpretation, but if you're interested in seeing the numbers and reading the highlights, it's all right here.

Thursday, January 12, 2006

Recycle your bits, as well as your atoms

This is something I posted a while back on Stayin' Alive. I think it will help establish the foundation that Blake is building here.

Here's a little essay I wrote with my colleague Anthony Schlaff, MD, MPH. (He asked me to tell you that the MPH is the important part.) We couldn't get it published anywhere respectable, so you'll just have to put up with it here.

Lost in Space

Imagine you are on a scientific team planning a trip to Mars. NASA tells you to prepare based on the following assumptions:

1) There is a breathable atmosphere on Mars

2) There is drinkable water on Mars

3) The temperature on Mars averages 60o Fahrenheit.

4) You can travel faster than light

Edgar Rice Burroughs did exactly that. But would you sign up for the trip?

Those who claim we can solve the problems of health care access and cost through the “free market” are thinking like Edgar Rice Burroughs. If you ever took an economics course, your teacher probably introduced you to the key assumptions of market systems. They include:

1. Perfect information – Buyers know everything, or at least enough, about products offered for sale and the possible alternatives to make a “rational” decision.

2. Consumers generate demand, all transactions are voluntary – Buyers decide what they want, and when to buy it.

3. Balance of market power – There are many sellers and many buyers for every product, who freely compete.

4. No externalities – All of the costs and benefits to society that result from a transaction are felt by the buyer and seller.

5. Adequate circumstances and justice.

Do any of these apply to health care delivery? Not a one!

Information: Fundamentally, what we buy from our health care providers is expertise. Because we usually can’t assess their competence ourselves, doctors, nurses and therapists have to go through legally approved training and be licensed by the state.

Demand: Imagine if Ford and GM could decide when we needed to buy a car – that doesn’t sound much like anybody’s idea of the free market. But doctors tell us we need surgery. That’s called provider-induced demand. While doctors try to be responsible and objective in their decisions, it has been shown that the way in which they are compensated does affect the amount and kind of medical services that they prescribe.

And our consumption of medical services is frequently not voluntary at all. If we have a dissected aorta, you could argue that in some abstract sense we could choose whether or not to have surgery, but common sense tells us we are compelled. We could even go into the Emergency Department unconscious, and only find out later what services we had received.

Market power: We can go to the supermarket and pick from a dozen brands of toothpaste, and most of us can also choose where to shop. But outside of the major cities, most regions are served by only a single hospital. Hospitals are very expensive to build, equip and operate, so it would be wasteful to have more, but that means our choices are limited. There are also structural reasons why most of us have at most two or three insurance companies to choose from, and of course many drugs are patented.

Externalities: Although we are most familiar with so-called negative externalities, such as air pollution from automobiles, medicine actually has many positive externalities. Treating and preventing infections benefits people who would otherwise catch the disease. People who can’t work due to preventable or treatable disease and disability contribute less than they could to the economic support of their families, the net economic production of society, and non-monetized but socially important activities such as child rearing, homemaking, etc. And there are what might be called moral externalities. Most of us would be troubled by large numbers of people with treatable illnesses in our midst, and even more distressed if those included people we knew and cared about.

Justice: We never know when we or our loved ones might suffer from a serious disease or an injury. Most people cannot possibly save enough money to pay for their care if they are badly injured in a car crash, or their child is diagnosed with leukemia. Such events can bankrupt people and destroy their lives. That is why we have insurance – to spread risk, so that everyone pays an amount they can afford, and those of us who suffer misfortune are taken care of.

Last year, our old friend William Frist, M.D. (of the long distance diagnostic powers), in a lecture at the Massachusetts Medical Society, said, “We must agree on a guiding principle: all Americans deserve the security of lifelong, affordable access to high-quality health care." It's nice to have a principle that says people deserve it, but it's even nicer to have a plan that will give it to them. This Senator Frist does not have. His system of "consumer driven health care" is driven by consumers in the sense that they pay for it, out of their own pockets. People who earn more than $40,000 per year "should be encouraged, through changes in the tax policies, to buy themselves and their children high-deductible catastrophic insurance coverage." They would then pay for routine care through tax-free Health Savings Accounts (HSAs). Frist also wants to eliminate the tax policies that encourage employers to provide insurance. He says that the system of employer-provided health care "has been universally blamed by economists for inflating health care costs." However, the reference he gives says no such thing, and the assertion is false.

The truth is that economists blame our fragmented system for our high costs, but Frist's solution is to make it even more fragmented. The other wealthy countries spend much less on health care than we do, and get better results, because they have concentrated market power on the purchasing side, either single payer systems or multiple payers who work within budgets established by governments (e.g., Germany). By driving a bargain, they get lower prices for drugs, medical devices, etc. Also, in our complex system, each provider needs systems for billing dozens of different payers, while the payers have their own overhead and marketing expenses. A quarter of total U.S. health care spending is on administrative costs. Note that in our public insurance programs -- Medicare and Medicaid -- administrative costs are far less.

In the real world, the people who establish HSAs will mostly be healthy and wealthy. These people will no longer be in the pool for comprehensive insurance, the price of which will then rise. Although Frist appears to believe that insurance will be more "affordable" because of competition among providers and health plans, the fact is, they already compete in a market with many large, powerful corporate buyers. By phasing out employer-provided insurance, leaving individuals try to buy insurance on their own, this concentrated purchasing power will disappear. Frist's world is a jungle in which the fortunate will be rewarded and the rest of us will be unable to pay for health care.

Medicine is not just a private good, it is also a public good, like park land, national defense, or law enforcement. It is in fact a mixed good, like education, benefiting both the individual and society. Hence, if we leave it up to the consumer to decide when and what to buy, the public good represented by medicine will be underproduced. Imagine if the "Ownership Society" included the elimination of public education -- the logic is the same.

Champions of market reform in health care have been getting away with proposing fiction as reality for far too long. Both theoretically and empirically, the key market assumptions described above have clearly been shown not to apply to health care. Let’s come back to earth and stop pretending that they do.

Wednesday, January 11, 2006

American Medicine's Denial of the Anatomical Existence of the Neck?

Ok folks. In my "Etiology" post of 3 Jan I wrote about six reasons why our US HealthCare system is real-time failing before our very eyes (and bodies). Last week, on Jan 6, I covered Paternalism which I hope was helpful? Today I am writing about the current limitations of what we call Reductionism especially as applied to the chronic diseases that we Americans now suffer and die from. Our health care (whoops-disease care) system, from bio-medical research to clinical practice, to reimbursement mechanisms is dominated by reductionism which in short attempts to isolate a single cause for a single disease or single health outcome. It all started with a "power of personality" 17th century French Philosopher- Rene Descartes (1596-1650) who struck a “deal” with the church that Docs would take care of the body but the mind and soul were to be excluded from the province of scientific medicine (that is not-mind you- a geographic Province in France) Well Descartes model actually worked well for a 3 centuries -give or take -because infectious diseases were killing so many global citizens. (They still kill people in "un" and underdeveloped countries) One you could say that the single cause model worked almost to a miraculous degree especially here in the good ole US of A. Smallpox has been eradicated -we are getting closer to worldwide polio eradication and so many heretofore lethal infectious diseases like tuberculosis and scarlet fever have been treated successfully with antibiotics. We'll as they say no good deed, medical model, or medical paradigm goes unpunished. By the 1950s in the US scientists began to notice that our fellow citizens were dying much more from chronic diseases such as heart attack, stroke and cancer than infectious disease. After billions were pumped into "finding the cause" of these modern killers (see Nixon’s failed reductionistic "War on Cancer" it became apparent that these chronic disease were indeed multicausal. So we now know that these chronic diseases are contributed to by genetics, diet, environment, lifestyle, and yes, even stress. Well in regard to especially the latter, poor Descarte began turning over in his grave -(See Descartes' Error : Emotion, Reason, and the Human Brain -- by Antonio R. Damasio 1998) and contemporary reductionists began to panic, but a new Bio-Psycho-Social-Spiritual (BPSS) model was being born. Some call it a holistic model. (see A debt of gratitude must be paid to pioneer Dr George Engel, an internist and psychoanalyst, (1913-1999) who mostly in the 1960's and 70s at the University of Rochester tried to advanced his Biopsychosocial model (he didn't dare touch spirituality leaving alone the work of the late great Carl Jung-too mystical for science). But alas Engel’s then was largely lateralized by both Bio-Medicine and Psychiatry because of resistance to change and perceived loss of power and money on both sides-often the curse of the pioneer. I began to use the phrase "Reductionism's last hurrah" in 1985 is essays I wrote and speeches I delivered. Now, please don't get angry, I am no anti-technology Luddite but bio-medicine alone is simply incomplete! Rather a BPSS model leverages the miracles of modern bio-medical technology by fully integrating contemporary psychology, sociology, and theology. Also, once one accepts that the Central Nervous System (CNS) or mind influences all health outcomes it must follow that anything in the universe from objective stimuli to anything perceived or even thought or imagined can and does impact our physiology and health outcomes. (Viruses, alas, still trump hope or prayer) So for 300 years plus the anatomical existence of the human neck which serves to attach the head to the body was denied by medical science despite the fact that everyone that I have ever met or every patient that I have examined seems to have one? (fyi-my collar -or noose?- size is 17 inches) Cervantes has also brought your attention in this blog and Stayin Alive the need for Sociology and to be fully integrated with modern bio-medicine. How can we afford economically, ethically and morally to continue to medicalize America's social problems like poverty, cultural xenophobia or outright bigotry. In short we can't! There is no pill for not having a job or no surgery for people of color not having access to basic health care. From a practical perspective I have personally lobbied JCAHO to require that physicians ask two simple questions to all patients- "How are things at work or school?" and "How are things at home?" Those two simple questions might get this model off to a good start? And patients, of course know this being way ahead of their providers. We could use the famous JCAHO "fifth vital sign" of pain on a 1-10 Likert scale that JCAHO requires be asked by providers to hospitalized patients as our model. (After all folks, hospitals do need that JCAHO certification for big Medicare dollars). But alas, however, JCAHO does not yet certify outpatient practices. Here are my five practical actions to advance the BPSS model.

#5 Practical Actions to Advance a Bio-Psycho-Social- Spiritual (BPSS) Model of Health Care

1) Support Mental Health Insurance Parity Laws. Encourage
patients to seek counseling or psychotherapy during any

2) Switch your primary care Doctor if he/she doesn’t ask you “how are things at work or home?” during every office visit (see Lippin-Simple Mandatory questions”)

3) Be certain that your Doctor(s) and other health care providers are aware of your religious and/or spiritual needs especially during major life transitions, crises, and at end-of life.

4) Try to find meaningful, safe and healthy lifelong work. Support job creation legislation and healthy workplace legislation/regulations. Encourage more research on meaningful work as a health outcomes issue.

5) If you are unable to find a meaningful daily job- find a
meaningful passion and integrate it into your life. Advance
research into this area as well.

This new model is also driven by stunning recent advances in neuroscience and will make the inflated promises of the "genomics revolution" (more reductionism) look like childs play. Is reductionism dead? Not quite yet. But it is very "Critical Condition" and is a major contributor to our moribund Disease Care system. For two very fine books in this area I highly recommend Manifesto for A New Medicine by James Gordon (1996) and the incomparable Larry Dossey book Reinventing Medicine (1999) My personal website at (whoops I revealed myself) explores this BPSS model

Tuesday, January 10, 2006

Trillions and Trillions

The Centers for Medicare and Medicaid Services (CMS) actuaries have released their annual report on national health care spending. First, I have bad news. This work, which was paid for by you, the taxpayers, and conducted by federal employees on behalf of your federal government, is not available for you to read unless you happen to subscribe to the journal Health Affairs, which costs $122 a year. CMS issued a press release about this, and then directed people to Health Affairs if they want to read it. So you rabble, wretched refuse, and little people can read the abstract only, here. But you'll have to depend on me to tell you what it actually says.

Oh, and now I suppose you were expecting the good news? Well, the article title, and all of the news coverage that depends on transcription of the CMS press release, emphasizes that spending "slowed" from 2003 to 2004. Actually, it increased by more than the overall growth of the economy, as it always does, but just not by much as it has in the past couple of years.*

Specifically, what they call National Health Expenditures (NHE -- which doesn't include public health, not that it would matter because it's so little) constituted 7.2% of GDP in 1970, 9.1% in 1980, 13.8% from 1993 to 2000 (the era of managed care, which temporarily restrained spending), and 16% in 2004. That's called "slowing" because it's only a .1% increase from 2003. The reason for the "slowing" (by which they actually mean reduced acceleration) is mostly that insurers are trying to steer patients and doctors to more generic and fewer brand name drugs; and the collapse of the market for expensive Cox-2 inhibitors. Otherwise, however, spending on hospitals and physician services just kept on rising without stopping for breath. By the way, it's just a number, but the total NHE in 2004 was $1,877,600,000,000. Yup, that's almost $2 trillion, which we should easily have hit in 2005.

Of this, the share spent by government at all levels was $847,300,000,000, or a somewhat less than half. However, the rate of government spending increased by more -- 8.2% -- than the increase in private spending -- 7.6%. But this 8.2% was a composite of the increase in Medicare spending (8.9%) federal Medicaid spending (6.6%) other federal (9.1% -- which includes the Supplemental Children's Health Insurance Program, VA and military, federal employees, etc.), state Medicaid (10%) and other state and local (6.1%), so as you can see the share of health care borne by various programs and units of government is shifting.

As for where the money is being spent, as I said, growth in spending on drugs slowed a bit, while spending on hospital care accelerated, to an 8.6% increase, and spending on physician service also acclerated, to a 9% increase. This is mostly because people are using more services, and more costly services. And by the way, spending on nursing home care grew much more slowly, at 4.3%, which helped contain what would have otherwise been a larger increase in overall Medicaid spending. (Medicaid pays for about 40% of all Skilled Nursing Facility costs.)

So the aging of the population contributes only a small amount to these inexorable increases. The main reasons? New medical treatments -- once they're available, everybody (with insurance) has to have them; rising prices; and increasing utilization. The reasons for the latter aren't entirely clear but the growing chronic disease burden -- of diabetes and heart disease, in particular -- probably has something to do with it.

As insurance premiums rise, more and more workers are forced off the roles of the insured. States have responded to the increasing burden of Medicaid by restricting eligibility and services as well. So the more we spend, the more inequality we create. Fewer and fewer people are the beneficiaries (or the victims, in some cases) of more and more spending. It has to end somewhere, but that end is not yet in sight.

*They aren't terribly specific about their data sources, but IMHO these estimates are pretty accurate.

Addendum: Here's a good link from our friend Keeping Eyes Open, which discusses the growth of health care spending in context, along with some recommendations for what to do about it.

Monday, January 09, 2006

Is the genie all powerful?

George Anstadt, in a comment on Blake's post on the etiology of crisis, draws attention to the potential benefits of new forms of information technology in health care, which he calls the "digital Genie." This seemingly very wonkish field is one that we should all try to learn something about, as health care consumers and as citizens.

Health Affairs recently published a theme issue on this subject. (Unfortunately, non-subscribers have access only to abstracts of most articles.) The more conventional term is Health Information Technology, which incorporates Electronic Medical Records (EMR) and Computerized Physician Order Entry (CPOE). These are linked, in that the physician's orders automatically enter the medical record, and information in the medical record can theoretically alert the physician if it affects the appropriateness of an order (e.g., a drug allergy or other counterindication).

People hold out great promise for HIT. If all, or at least most provider institutions used the same data format, medical records could be easily exchanged between doctors and hospitals. Consumers could, in principle, truly own their own records because all the records from all providers could be aggregated on a single server. (Did you know that legally, you already own your own records? You can ask to see them, and get copies. But hardly anyone does.) The record system could be programmed with "process of care standards," so that if someone was due a vaccination, or a screening test, the physician would be automatically alerted. They would also provide comprehensive databases of patient medical and treatment histories so that statistical analyses could be readily done establishing the compliance with quality standards of individual practitioners, hospitals, and health networks. CPOEs could be programmed to reduce prescribing errors and adverse events. The systems could automatically send reminders to people with chronic conditions about self-care. And so on.

This all sounds good although as Dr. Anstadt points out, it won't do anything directly about financial and other barriers to access. But as excited as many people are by the promise of such systems, there is a long road to travel before reality can be even close to the vision, and many potential pitfalls. Famous curmudgeonly critics David Himmelstein and Steffi Woolhandler, in the Health Affairs issue, run down the down side.

First, there's been talk of this digital revolution in HIT for decades, but progress has never come close to the hype. Many hospitals have installed computerized systems that they have ultimately abandoned; and while HIT has indeed gradually been installed in more hospitals, the much-touted safety and quality improvement capabilities are often lacking, and don't always work.

A major problem is that electronic systems don't do anything by themselves. They have to be integrated with human work processes and individual human behaviors. This is extremely difficult to achieve. It is also far from straightforward to determine what really constitutes quality of care. While numerous so-called "process indicators" have been developed -- e.g., what tests should be performed under what circumstances, what drugs should be prescribed, etc. -- there is little evidence linking any of these to better outcomes, and many physicians resist them on the grounds that all cases are individual and their judgment may override the one-size-fits-all recommendation. There is also no particular reason to think that patients will generally comply with the reminders and recommendations the systems generate for them.

Economics are also a problem. These may be good investments for large hospitals, but probably won't repay the investment for small and mid-size physician practices and community clinics. (They might repay the investment from a social perspective, but that won't motivate, or even enable, the individual practices to invest.) There would have to be a substantial government subsidy. They also require technical expertise to install, operate and maintain which doesn't currently exist. And inter-operability -- the single standard so that records will really be portable and exchangeable -- is a huge task that will require a major government investment and mandate, which will be accompanied by massive controversy. There is little discussion in Health Affairs of the privacy issues but they are obviously huge.

So HIT is a tool. Like any tool, it has to be wielded by a skilled user, or in this case, millions of skilled users, all working in concert, within systems of work that function effectively with the technology. A hammer and saw won't build a house, that takes a carpenter. We may be able to use HIT to make health care better, but the basic issues diagnosed by Blake will only be solved by people.

Friday, January 06, 2006

Paternalism-It's All About Power-Maybe?

In my "Etiology" post on this blog on Jan 3 I put forth, for your consideration, my six causes for the current crisis in US organized medicine. The first I noted was paternalism. In today's essay I will explore this complex controversial issue to be followed by future essays on my other five causes of our real-time current US medical meltdown. Paternalism has always been associated with healing from historic physician-priests, shamans, to contemporary white-coated "MDieties" who deign to receive the supplicant patient so that magical, mysterious and most importantly secretive cures can be administered to the eternally grateful patients. Not only are the cures known only to the healers but a secret specialized language is developed among the healing fraternity. Unfortunately this paternalistic model is based on power dynamics that infantalizes patients keeping them forever dependent on their doctors. I once published perhaps an extreme statement that "the best medicine is simply helping people to become themselves". Now mind you, if you have the misfortune of being born with a huge hole in your heart, or a truck driving 60 miles per hour hits your body broadside, or you develop a life threatening disease like cancer or a stroke you need a highly skilled technical physician pronto!- or stat! as they say in medicine. At that moment in time "becoming yourself" is a silly issue. But a large proportion of medical encounters (>70%) are not that at all. Most rather relate to physical symptoms and diseases that are attitude, behavior and lifestyle related or for example having a "toxic boss". Well, anyway, paternalistic systems (another example being organized religion) begin to fail when two related things happen-when patients become educated and when they become mature. They henceforth expect or even demand that their doctors relate to them as adults who can actually think. Regarding the neo-educated mature patient the internet has dramatically and profoundly changed the doctor-patent relationship. At least 88.5 million US adults will use the internet for health information over the next five years accessing no less than a whopping and growing- 20,000 health related websites. In some cases especially intelligent, persistant or sometimes desperate, computer literate patients will know more about current science and options for diagnosis and treatment for their disease than their doctors. This is a very painful transition for paternalistic docs who don't have the maturity to work with a educated patients. So the era of co-decision is now upon which also places more responsibility on patients some of whom fear that "burden" or even worse "abandonment". In addition to the internet the free market which I will write about in a future essay -if it is truly free-(currently it is not e.g.- largely a physician monopoly and AMA restriction of trade) allows patients to choose all sorts of providers who they can relate to as adults. US organized medicine is trying. For example to see what the AMA says about paternalism you check out this site. .But I remain convinced that this rhetoric is not matched by the AMA's or its members' real practices. After all there is a lot of power and big money at stake which is perpetuated by paternalism and dependent patients. But I recognize it ain't easy for any of us to grow up. Let's hear from you on this difficult but necessary transition for all of us. For any excellent essay on "deconstructing paternalism" I highly recommend from of all places Singapore:)

Thursday, January 05, 2006

Yes, we take requests . . .

A reader inquires about the process of new drug development and approval. A vast subject indeed. First, I definitely recommend as a good critical introduction Marcial Angell's piece in the New York Review of Books (yes, yes, effete east-coast pointy-headed intellectual elitism) from 2004.

Without trying to do it justice, I'll summarize one of her main points by saying that the profit motive leads drug companies to direct their efforts toward maintaining monopolies on drugs that they can sell a lot of, at a high price. Once they lose their time-limited exclusive rights to sell a drug, it's far less profitable for them. They have concluded that the best way to maintain profitability is not to try to develop novel treatments (and most of the creative energy that does lead to new therapies comes out of publicy-funded research anyway), but rather to develop slightly different versions of old drugs that they can get new patents on. Then, when their old drugs lose patent protection, they can use their enormous marketing budgets (considerably higher than their R&D budgets) to convince doctors to prescribe the new, still very expensive patented drugs instead of the now cheap generics, even though the new drugs aren't really any better, at least not for most patients. (Viz., Cox-2 inhibitors vs. NSAIDS; nexium vs. prilosec and even, for many folks, Tums. Etc.)

There are many other problems. Since the drug companies fund and control most of the clinical trials themselves, they can produce both subtle and unsubtle pressure to get favorable results and suppress evidence of harm. In particular, they don't have to test their new compounds against existing treatments, but only against placebos, or they can test them against sub-optimum versions of existing treatments (such as insufficient doses). So a new drug can be approved even if it isn't any better than existing drugs, or is actually worse. Also, the companies aren't particularly interested in finding adverse effects, obviously. It wouldn't be possible to find all the risks and side effects of new drugs prior to approval and marketing, for various reasons, but we could do much better, and all you need to be convinced is one word, Vioxx.

I could go on and on, but in answer to the reader's specific question, about drug companies selling rights, the key is that there are actually two kinds of exclusivity that they get: a patent on the compound, and marketing rights from the FDA. Once a compound is approved for one use, doctors can legally prescribe it even for unapproved, so-called "off-label" uses, but the companies aren't allowed to market it for those uses. So, in order to get marketing rights, they need to do a clinical trial to show (at least ostensibly) that it is effective for a given condition. A company might decide to sell the rights to conduct such a trial and market a drug on which it holds a patent for some new purpose, which is what appears to have happened in the case of Pfizer selling rights to a drug to be marketed as a treatment for stuttering. I have found that there is anecdotal evidence that drugs for anxiety -- such as Xanax -- may help some stutterers, since stuttering is compounded by the social anxiety that it causes for some people. Presumably Pfizer didn't think the stuttering market corresonded to their vastness, so they sold the rights to a smaller company to try to get a drug approved for the purpose.

This isn't necessarily a bad thing per se, but the standards for getting already licensed drugs approved for new indications are ridiculously low. This is often done with very perfunctory, small trials. That's why you see SSRIs now advertised heavily on television for everything from shyness to compulsiveness. It's very doubtful that they really help very many people with those problems. Of course, they don't do a whole lot for depression either.

See my post on Stayin' Alive about Bidil, for a particularly egregious example.

Wednesday, January 04, 2006

Our first guest post . . .

And it's a good one, from our friend Barry Levy:

Damaged Care:
The Musical Comedy about Health Care in America

Damaged Care: The Musical Comedy about Health Care in America is a 45-minute show that highlights issues of great concern to health professionals and health care consumers. Written and performed by two physicians, Greg LaGana and Barry Levy, the show features a number of issues including the excesses of managed care and cost containment, the inadequate attention to prevention, the success of “superbugs,” and the time pressures and isolation experienced by many health professionals and health care consumers. Damaged Care encourages health professionals and health care consumers to play leadership roles in improving health care.

The show, now in its 10th year, has been presented in 26 states to many different types of organizations and institutions, including hospitals and state medical associations, medical societies and public health associations, medical specialty societies and nursing organizations, educational institutions, and pharmaceutical industry organizations. Damaged Care has also been performed Off Off Broadway in New York, on Capitol Hill, at five conferences of the Estes Park Institute, and conferences of other organizations ranging from the General Assembly of the Presbyterian Church to Families USA to the Federal Reserve Bank of Boston.

Damaged Care has been featured in The New York Times, and on CNN Headline News, ABC Nightline, PBS HealthWeek, the Joey Reynolds Show on WOR Radio nationwide, the front pages of the Boston Globe and the AMA's American Medical News, and elsewhere.

Damaged Care and its creators are featured in the current issue of Lifestyles Magazine. The article can be accessed at:Lifestyles, or at the Damaged Care website.

Thanks Dr. Levy, sounds like our kind of show.

Tuesday, January 03, 2006

Roots of US Health Care Crisis ("Etiology")

Assuming you agree the US is in a multidimensional health care crisis- some would say rapid meltdown- let me put forth for your consideration and, please input, the six factors that I believe have led us to this crisis stage. Each will be explored in future postings by yours truly. They are –1) A paternalistic model which attempts to perpetuate an ignorant and infantilized patient population 2) Excesses of reductionism (single cause for single disease) in bio-medicine which for chronic diseases is failing 3) The US love affair with expensive technological solutions for all human problems 4) The US peculiar obsession with only free markets and the private sector to deliver health care 5) The failure to prevent disease and promote health 6) The excesses of the legal profession’s influence on health care delivery(emphasis on the word excesses please)

Now let’s be realistic - $1.8 trillion dollars worth of entrenched vested “industrial” interests are not exactly ready to roll over easily but several dynamics favor change- yesterday. Public opinion polls increasingly demonstrate the political importance of health care and health care costs to American voters. Some say, after the general economy and the war in Iraq it is the number #3 political issue in 2006. Politicians like to get elected and re-elected. They are listening despite obscene funding and relentless lobbying by the “Disease Care” Industry. Secondly we simply cannot as a nation afford to spend close to 15 % of our GNP on health care and significantly more on a per-capita basis per US citizen (@$5300 dollars per person -almost two and a half times the industrialized world’ median of @ $2,200 dollars) than any peer industrialized nation and expect to maintain the US quality of life we have come to enjoy “duh”.Yet, despite these excessive expenditures, quality of health care as measured by a host of objective measurements is declining? What’s wrong with that picture? “double duh” Finally, being a country founded on Judea-Christian ethics, the ethical and moral depravity that the US health care industry now manifests is incompatible with our nation even pretending to exhibit moral leadership as “a beacon to other nations”. The US remains the only nation among nations in the developed world (except for South Africa) that does not provide some level of health care for all its citizens. These three dynamics make change both inevitable and imminent! The question I keep asking myself is do we need a total system meltdown and collapse before a new US health care system arises? Or in other words “I never underestimate the self-destructiveness of institutions entrenched in the status quo”. On this latter observation I sincerely hope I am wrong.