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POLICY: Debating SICKO’s Impact by John Irvine

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Since opening a week ago, Michael Moore’s latest documentary has focused unprecedented attention on the U.S. healthcare system. The film has brought angry protests outside movie theaters. Standing ovations from audiences. And provoked angry debate in the nation’s editorial pages. It has also done fairly well at the box office, drawing far more viewers to theaters than many experts had predicted.  According to the Hollywood Reporter, the film finished second in per-theater gross last weekend, bringing in $11.3 million at 700 screens across the country — rather a respectable showing for a movie that specializes in disturbing subjects that Americans would generally rather not talk about. So far, Sicko has generated exactly the kind of controversy that the critics predicted it would.  Moore has  already had to deny that he is planning a trip to Iran next month to view the film at an Islamic film festival. (The story turned out to be a rumor spread by conservative opponents.  The filmmaker says he received an invitation from the Iranians but declined to accept.) This week he was on CNN, lambasting the network for its healthcare coverage and getting into a near shouting match on The Larry King Show with medical correspondent Dr. Sanjay Gupta over some of the stats used in the film.

Moore went on to accuse the network of colluding with the film’s
opponents, pointing out that one of Gupta’s researchers, Paul Keckley,
the former head of Vanderbilt’s Center for Evidence Based Medicine and
a current Deloitte consultant, has done a lot of work for big health
insurers and pharma companies
. (Something that could be said of a fair number of people working in the field, as THCB readers know all too well.) Could Keckley be censoring the network’s coverage?  Moore wondered out loud to himself and not-very-subtly. 

The theatrics aren’t a surprise to anyone who has followed Moore throughout his
career. Not surprisingly, the attack drew a rather hurt denial from Gupta on his
CNN blog
.

Meanwhile, Moore is living up to his reputation for drawing attention to himself. Earlier this week, the filmmaker published a leaked internal memo on his web site allegedly authored by
the Blue Cross communications department.  The document reviewed the film – acknowledging that the documentary is a slickly done piece of work. [Follow the link and scroll down to read the whole thing.] The review begins as follows:

"You would have to be dead to be unaffected by Moore’s movie, he is an effective
storyteller. In Sicko Moore presents a collage of injustices by selecting
stories, no matter how exceptional to the norm, that present the health
insurance industry as a set of organizations and people dedicated to denying
claims in the name of profit. Denial for treatments that are considered
"experimental" is a common story, along with denial for previous conditions, and
denial for application errors or omissions. Individual employees from Humana and
other insurers are interviewed who claim to have actively pursued claim denial
as an institutionalized goal in the name of profit. While Humana and Kaiser
Permanente are demonized, the BlueCross and BlueShield brands appear, separately
and together, visually and verbally, with such frequency that there should be no
doubt that whatever visceral reaction his movie stirs will spill over onto the
Blues brands in every market."

Will the public hold health care providers and insurers accountable for the lapses Moore documents in his film? That remains to be seen. For many Americans who haven’t been paying attention, the documentary is undoubtedly a wake up call. There seems little doubt that people will start to ask more questions when they walk into their doctor’s office or when they sit down to pick an insurer, which is certainly enough to make some people uncomfortable. There is also little doubt that the film has added to the already fiercely burning debate between supporters of a free market based system and a government run universal healthcare system.

PODCAST REVIEW: Here’s THCB contributor Dr. Eric Novack’s take on the film from his radio show last Sunday. Two thumbs up? Er, No. Here’s Part 1 and Part 2. Eric and I will get into this a little later on, we hope!RELATED: "Sicko and Healthcare Reform", Maggie Mahar’s piece on THCB drew thousands of readers  and led to excellent discussion.

Dispatches from IHI’s quality forum

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Don Berwick is one of the leading lights of the health care quality world; an
oft-quoted and published visionary who founded the Institute for Healthcare Improvement to spread the gospel of transformation and improvement around the world. Sometimes, however, he can come across as messianic, especially when preaching to the choir in a setting like the IHI Forum, which took place last week in Nashville.

Some criticize Berwick and IHI for a lack of measurable outcomes for the interventions they preach. The most recent complaint like this concerns IHI’s 5 Million Lives campaign, which recommended that hospitals adopt a series of interventions to improve patient safety, promising that if they did so, 5 million patients would be saved. 

The campaign officially ended at this week’s conference, and no one at IHI can show data on the number of lives saved. It’s true that Berwick has a powerful voice and a broad platform, and he could use it to structure the work that needs to be done, rather than sticking to a combination of inspirational cheerleading and emotional appeal. But back when no one was thinking about quality, Berwick was championing it; and for some community hospital quality leaders who feel like they are the lone voice in the wilderness, his words keep them going all throughout the year.

QUALITY: Back surgery request

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A great friend of mine is looking for back surgery information. As we know this is one area where not much is know about what works. Any ideas? If so please comment:

I’ve been dealing with a couple of herniated disks in my lower back for the past
2 years.  Over that period of time, I’ve tried treating the pain with epidural
steroid injections, physical therapy, manual manipulation and deep tissue
massaging, acupuncture, and lots of fun pain "cocktails".  These treatments have
provided, at best, temporary relief from the pain.  And lots of crazy
hallucinogenic dreams! 

Last week I had a discogram (a diagnostic procedure to determine how badly
damaged the disks were), to enable my doctor to determine what type of surgery
would be best.  Talk about hallucinations… that Demerol is good stuff!  We
went through the results last night and, unfortunately, it’s worse than we
thought it would be.  One of my disks is so badly torn across the posterior of
the disk that procedures like a diskectomy or laminectomy won’t work.  I have
the option of either full disk replacement (which is a pretty involved abdominal
procedure where they replace the disk with a stainless steel mechanism that
works on a ball & pivot system… call me the "bionic woman") or a procedure
called an Intradiskal Electrothermal Therapy (IDET) that essentially cauterizes
the outside of the disk to kill some nerve root endings and seal off the tears
in the disk.  It sounds pretty high tech and cool… if it weren’t going to be
performed on me! 

My understanding is IDET is a short-term solution and, eventually, I’ll
need to have my disc replaced.  But I’ve also learned that there are a lot of
new disc replacement technologies in the works so it’s in my best interest to
hold off on the more involved procedure.  That said, I’m leaning toward the IDET
option since it seems the least risky course of action and could potentially
reduce my pain immediately with no major side effects.  Unless you count the
humiliation and trauma from having to wear a stiff plastic corset for 10-12
weeks after the procedure? If you know someone who has had disc replacement surgery or an IDET
procedure and is willing to talk with me about their experience, I’d really
appreciate it!  Also, if you have any recommendations of really good surgeons
for my second opinion, I’m looking for referrals, too. 

Re-Decentralization of Medicine: The HIE of One

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This week, a non-commercial, open source proof of concept called HIE of One becomes the first standards-based patient-centered health record demonstration. It uses the emerging FHIR standard along with established standards for identity and security management to show how a physician-patient relationship can be independent of any particular institution and therefore as de-centralized as your smartphone messages or your Bitcoin payments.

The history of patient-centered health records begins in 1994 with the Guardian Angel Project at MIT and has inspired many of us. Implementations have come and gone over the past 22 years and today’s massively centralized and institutionally controlled EHRs seem to be headed further and further away from a patient-centered vision. Hacking and information blocking are a concern for patients and legislators. EHRs and government meddling are a source of frustration for physicians. Technology, however, is finally catching up with Guardian Angel’s promise.

TECH: Trotter wins beer with Bush

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Fred Trotter says that he won the beers with Bush (Jonathan Bush of AthenaHealth, that is) on HISTalk. I suppose he’s going to use his time to persuade Johnathan to put his source code on the Web!

POLICY: Two awful stories

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Just before you get too lost in the wonkiness of health policy, just remember the financial implications of being sick in the wrong circumstancesin this country. Here’s a woman with a sick kid who is going to have her husband take a pay cut so that she can qualify for S-CHIP.

And here’s a benefit tonight in Richmond Virginia, for Kellie Brown, a student who needed an emergency appendectomy and has dropped out of college to pay of the $10,000 she owes. I kicked in a few bucks; if you’re feeling nice you might too.

Think of the economic insanity of these two things–someone dropping out of college, and someone moving to a lower pay grade because of health care costs!And no, this shit does not happen anywhere else in the civilized world.

POLICY: Eric Novack responds

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Here is a fundamental problem with the debate that Matthew is having with Amy Ridenour and David Hogberg: Matthew (and single payer advocates generally) focuses his attacks on the general ‘injustice’ that might exist in the healthcare system. In the face of such injustice, the theory goes, the government must step in to ‘even out’ the system (another way of saying that the ‘risk pool’ for unhappiness ought to be as big as possible—or, put another way, misery loves company).

“Free marketeers” (presumably an effort on Matthew’s part to turn those who believe that less government intervention actually is good for economies—for which the evidence is incontrovertible—into a pejorative) are generally no more happy with the current system than ‘healthcare-by-lobbyist’ activists (my own pejorative for bureaucrat run healthcare). However, people who believe in markets want to introduce free market reforms, recognizing that this process must be incremental.

Put another way—single-payer advocates speak in broad generalities of fairness and justice and risk pools—which sounds great to the public, but is short on actual policy implementation. Limited government advocates have, thus far, been focused on actual concrete steps to improve the system.

HEALTH PLANS/POLICY: Meter Reading–How Regulation Might Fail

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Today I’m up at Spot-on in a piece about the influence of big health plans on reform efforts called Meter Reading: How Regulation Might Fail.

Maybe, just maybe, we’re getting serious about health care.


This week’s news says yet more unlikely allies are advocating healthcare overhaul.


The alliance between the Business Roundtable, unions and interest groups – an even more unlikely bunch of reformers than Republican Gov. Arnold Schwarzenegger and the insurance association  (both already out with their own plans) –  are all saying, loudly and clearly, that something must be done. It’s all leading to an odd sense of optimism – one I don’t, sadly share.


Forces outside of health care are starting to talk the talk about
forcing change. Former Massachusetts governor and Republican
presidential hopeful Mitt Romney’s health plan, the election of a
Democratic majority in Congress, and ever- increasing costs are all
forcing everyone to get those old reform plans out again. And as
evidenced in this discussion even political columnists from the
WaPo think that something is going to happen – although they do tend to misread the light at the end of the proverbial tunnel. Continue

As ever come back herre to comment

POLICY: Low Payments by U.S. Raise Medical Bills Billions a Year

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Freudenheim punked twice in 2 weeks? Apparently so. More in the morning

Johns Hopkins professor presents on improving patient-physician communications

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WHO: The Herschel S. Horowitz Center for Health Literacy at the University of Maryland School of Public Health hosts guest speaker Debra Roter, DrPH, as part of their ongoing Speaker Series.

WHAT: Dr. Roter, a Professor at Johns Hopkins Bloomberg School of Public Health, will present a lecture entitled "Improving the Quality of Patient-Physician Communications: A Prescription for Health Literacy." She will discuss her research into how doctors and patients speak with each other and present strategies on how to improve both their interactions and the health outcome of patients.

WHEN: Friday, January 30, 2009 from 2:00