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PHYSICIANS: An Open Letter to Harvard Medical School By Dr. Terry Bennett

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Doctor Terry Bennett
became the focus of national attention two years ago when he brusquely told an
overweight patient that she was fat, warning that unless she changed her
lifestyle she faced serious healthcare problems. The woman complained to the state Medical Board.  Last year, the New Hampshire physician  fought off the attempt to punish him. The
experience convinced Bennett that the practice of medicine in America must change.

Like many physicians he
believes that doctors are treated unfairly and that the healthcare system is on
the verge of collapse.  He argues that
out-of-control HMOs, high malpractice rates and the financial burden of earning
a medical education are ruining the  practice of medicine, creating a generation of
young doctors that has forgotten what makes a doctor a doctor.

Instead of sitting in
his office in Rochester, New Hampshire  and watching it happen, Dr.
Bennett has decided to do something about it by nominating himself for one of the highest profile jobs in
medicine. He recently launched a "write-in" campaign to interview for the Dean’s
job at Harvard Medical School, generally considered the cultural heart of
the medical profession in America. What follows is his open letter to the Harvard
search committee requesting an interview.  For the record, THCB neither
endorses nor opposes his candidacy. We
believe, however, that the views Dr. Bennett expresses are important and worthy of very careful
examination. He also turns out to be a gifted writer, which makes this piece a very compelling read. An insider at Harvard Medical School who must remain anonymous calls Dr. Bennett’s letter "one of the most beautiful pieces of writing on medicine I have ever read." I fully agree. —  John Irvine

To the search committeeHarvard Medical School

I would not press for the job of Dean of Harvard Medical School, at my age, and at my station in life, if I did not think the Dean’s job did not need a rethink, a change from, an inarguably good man, the present Dean and most of his predecessors, to a zealot, of sorts, with a considered and announced, very public, totally non-secret, pro patient anti "money only" agenda, one which will change the life/lives of the man/people on the streets of America, and by extension, the world.

Humor me a little:

Ask the first one hundred people you meet on the streets of Boston if they know the name of the present Dean of Harvard Medical School, or what, if anything, has he stood for, while he has been Dean, and how has his tenure positively impacted/affected their lives and those of their families?

What has the Dean of Harvard Medical School caused in the way of useful change in their lives? What has he changed, for the better, or at all?

I will be surprised if one person in one hundred knows his name, or thinks his existence in any way affects their lives, and so will you.

It is my belief that so much has changed for the worse in American Medicine, that the HMS Dean’s name should be a byword, his/her positions clearly known, and the positions inarguably pro bono publicum, as he/she struggles publicly to change the status quo, tries get the 45 million uninsured into a universal healthcare program of some kind or another, tries publicly to get US drug prices within the reach of patients, tries to get American community hospitals to return to full and fully charitable services offered to their communities, and vows to be producing debt free zealot "gonna go out and change the world" physicians from HMS to go out and effect the necessary change(s), before all is lost, forever.

Continue reading…

PHYSICIANS: Bennett YouTube Interview

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It turns out that Dr. Bennett is also a supporter of
universal healthcare.  He recently attended
a  rally for John Edwards, where Daily Kos caught up with him.

POLICY: Debating the Quality of VA Care By Eric Novack

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The many commenters and contributors
to THCB who have been touting the VA as the pinnacle of US health care—and
basing their conclusion that what we need is not ‘Medicare for All’,
but rather ‘VA Care for All’—have some explaining to do.

In this article, which reports the McClatchy
News Service’s investigation into the claims of the VA—the real
truth is not so rosy.

UPDATE: (5.11.07) Ed comments: McClatchy’s Washington bureau has set up a blog where you’ll find more detail on this story as well as related pieces on the military healthcare system.

POLICY: Freedom of Choice, Good for Education – Good for Healthcare By Eric Novack

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Proponents
of Sheila Kuehl’s ‘Single Payer’ health plan for California like to
lead with the argument that ‘Everybody in, nobody out’ is a good thing.
Of course, many of the same interest groups (ie. powerful lobbying
organizations in California) are vehemently opposed to school choice,
while demanding greater and greater regulations for what it means to be
a ‘qualified’ teacher.

Fascinating, then, the new study from USC’s Rossier School of Education.

The charter schools (read that to mean, more choices for students and
parents) do more with less funds, generally have fewer layers of
administration, and have fewer ‘licensed teachers’.

But it is all about outcomes these days—for both education and health care.
So how do charter schools stack up? From page 6 of the study:
California charter schools typically have smaller per-student
allocations than non-charter schools in their districts, yet charter schools have roughly equivalent levels of productivity: They get “more bang for their buck.”

Choice and freedom, and relieving the burden of excessive regulation and union
and other lobbyist control are good for education. The taxpayer
benefits. The student benefits. Society benefits.

So
why would the nurses union, whose members are on the ‘front lines’ of
healthcare, want to strip all choice and freedom out of healthcare?

H/T to the WSJ editorial page

PHARMA: What the Zubillaga affair may suggest, by The Industry Veteran

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We haven’t spent much time over here talking about the “buckets of cash” scandal that’s been keeping the pharma-focused bloggers very busy, and even less comment on the apparently expensive and rather bizarre purchase of MedImmune. Both concerning AstraZeneca. But The Industry Veteran has been wondering around on the grassy knoll and has come up with a very interesting explanation that links the two:

I spent a good part of the past two weeks in the unaccustomed position of defending AstraZeneca. Equity analysts and others in the pharmaceutical industry seemed astonished by the high price the company paid (a 52 P/E ratio) to acquire MedImmune. Their basic criticism amounts to a complaint that AZ acquired neither an auspicious, late-stage pipeline or a significant cash flow. Both observations are correct but AZ gained other benefits for this steep price. What AZ bought was a place for themselves in two businesses when they acquired MedImmune. Companies typically have to overpay when they want to get into a new game. Ten years ago Abbott paid 40 times earnings when they bought MediSense to get into the blood glucose monitoring business. More recently Novartis paid through the nose to belly up to the vaccine business bar. A few weeks ago Schering-Plough overpaid to buy Organon but Fred Hassan gained stronger positions for himself in the women’s health and the dermatology businesses. Given the current trough in Pharma’s new product development, it’s simply a fact of life that anyone seeking to consummate a merger or acquisition must be prepared to overpay. Fifteen billion dollars for MedImmune is certainly no more outrageous than paying a 42-year old pitcher $15 million for half a season.AZ placed a toe in the water of the vaccine business, something that does not resemble Pharma’s traditional goldmine because a high proportion of vaccine customers are public agencies. Nevertheless, the vaccine business is poised to grow, and if it receives a boost from a pandemic flu epidemic, it will grow enormously. It will also grow substantially if someone makes good on the effort to develop an oncology vaccine or immunizations for the many viral infections that threaten the length and quality of life.In buying MedImmune AZ also acquired capabilities for entering the biologicals business. At this point the multi-billion dollar products of companies such as Amgen and Genentech do not face the precipitous revenue losses that occur when Pharma companies lose patent protection on their products. This is because most regulatory agencies have not developed guidelines for determining acceptable thresholds to approve generic versions of biological products. Congressional waterboys for the biotechs, such as Sen. Ted Kennedy, want makers of generic biologicals to conduct the same sort of clinical trials for their products as the original developers of the branded biologicals. Faced with such high development costs, the generic model of low cost equivalents becomes unsustainable. Nevertheless, despite the disingenuous concerns of Sen. Kennedy and others, Congressmen wise to Pharma such as Henry Waxman and Bernie Sanders will eventually succeed in creating some form of "bio similar" legislation. The country can only tolerate so many stories about people who died because they were unable to make even the co-payments on biological medications costing between $40,000 and $200,000 per year. At that point there will be a major demand for an entire industry of generic biologicals.During the two weeks I was defending AstraZeneca’s purchase, CEO David Brennan and John Patterson, the VP for Clinical Development, did their best to undermine my claims about their wise purchase.

Continue reading…

POLICY: The New York Times, sigh

I guess I spend too much time getting grumpy about the use of space in the NY Times, but come on. Atul Gawande is a great writer who writes fascinating articles for The New Yorker. But when it comes to his solution for health care? He gets not one but two op-ed columns in the New York Times. And what does he say in Curing the System? Following the Massachusetts system might be an option. Or we can expand SCHIP. That’s it. To say the same thing I used one line.  I think the NY Times
owes me (or someone) 2 columns to really discuss health care. After all
they’ve spent plenty of time licking sores about the issue.

 

PHARMA/PHYSICIANS: ESRD centers having the curtain pulled back

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The NY Times shows that apparently doctors owning ESRD centers and others running chemo-infusions centers reap millions for Anemia drugs .
Who knew? OK, anyone reading THCB for the past few years knows all about this, but now that it’s hitting the NY Times (which got a former clinic director to open his version of the books showing that docs in a 6 person group made about $450K a year each on their sale of the drugs) and now that hearings have already been held, and the FDA’s issued a warning, perhaps something may change…

POLICY: Communism breaks out on Wall Street? (No not really)

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I sat through a very interesting talk about American health care yesterday afternoon. I guess I knew all this but it was good to have it laid out in front of me. Here are my notes from the talk about the health insurance market.

The overall number of people with private health insurance has been stagnant (176.9m) since 2000 while the workforce is growing (from 137m in 2000 to 145m in 2006). The number of uninsured is growing as are those in public programs. And as a consequence the “lives” growth in the big for-profit health plans has been below Wall Street expectations. Consumer directed health plans are growing and from around 9–10m lives in 2007 may end up at as many as 25m lives in 2010 (although those projections are much lower than they were a year ago).

Margins are as high as they’ve ever been and are at the top or even higher than the top of the underwriting cycle. Is the underwriting cycle over as they’re saying? Maybe but it’s been around for 50 years, and margins in non-profit Blues (which the speaker said aren’t so concerned about profits as the for-profits, which may be news to some non-profit CEOs I’ve met!) have started to trend down, and overall premium trend is moving down. Furthermore, some competition between plans is causing overall pricing go down (although some of that may be change in product mix, as more HDHPs which have lower premiums are sold).

Then there was a great chart showing that usually medical cost trend goes up with a 3–4 year lag to overall economic growth. We’re at about 3–4 years after the start of the most recent economic expansion now. So should we expect medical trend to go up, while premiums are going (relatively) down, and so in consequence expect the financial health of insurers to be getting worse? (My note: Is that why they’re trying so hard to hang on to those “extra” Medicare Advantage payments?)

Finally, we’re seeing employer’s provision of coverage to their employees go down, unusually, in the middle of a boom (the jobless recovery is not jobless, so much as benefit-less).

What did the speaker think was the likely outcome of all this? Bad news for health plans compounded by national health reform starting in 2009 lead by a Democratic President.

And from which lefty did I crib all this insight? Matt Borsch, health care analyst at that well known group of Bolsheviks called Goldman Sachs.

THCB UPDATE: Reader Mail

In response to yesterday’s post on AthenaHealth’s 2007 insurer ratings, Brian Klepper of the Center for Practical Health Reform writes:

I suspect that AthenaHealth would be unwilling to publicly report physician performance. Who wants to antagonize their clients?

But if AH has access to the information within the individual claims
records, it could add significant additional value by discretely
providing physicians with their relative performance values and
performance benchmarks. Physicians could use this information in health
plan negotiations and to guide performance improvements that will
become increasingly important as P4P takes root. At this point, the
only data most doctors have access to during contracting are the
numbers the health plans give them.

While health plans have actively campaigned for provider performance
transparency, their own performance has remained fundamentally opaque.
If this continues, it will render the changes possible through P4P –
which changes the incentives to reward the right care instead of simply
more care – much more difficult to achieve, because providers inherent
distrust will bubble over, as it did with managed care. After all, if
I’m not willing (or able) to tell a physician or hospital what
utilization or cost changes resulted from the incentive shift, or how
the savings were distributed, the conclusion will be that the health
plan simply pocketed the dollars with no savings to the system.

In this sense, AthenaHealth has taken a major step forward in
precipitating health plan transparency, and they deserve our collective
thanks.

That said, its useful knowing how long it takes for plans to pay
claims, but hardly what’s required to fully understand health plan
performance. A more robust tool is eValue8 (www.evalue8.org), developed
by the National Business Coalition on Health (www.nbch.org). This last
October, the Florida Health Care Coalition performed an evalue8
analysis of major health plans operating in Florida and then released
the results. These tools finally begin to provide a credible method for
purchasers and providers to get a handle on the complex, confusing
workings of health plans.

If AthenaHealth could leverage their resources a little further by
broadening their analysis, they’d add real value to changing the
dysfunction that plagues this part of the system. 

In a retort to the post on the growing support on Wyden’s health care plan, Barry Carrol writes:

I wonder about several things with the Wyden approach.First, how efficient will it be to, in effect, sell health insurance
one policy at a time as opposed to thousands at a time (through a large
employer)? The main problems with employer provided health care, in my
opinion, are lack of choices and lack of access to affordable coverage
if one loses or leaves a job or retires before becoming eligible for
Medicare. An employer mandate, at least for all but the smallest
employers, coupled with lots of choices similar to the Federal
Employees Health Benefits Plan might be a more workable approach.

Second, the Massachusetts experience is instructive on several
levels. First, Massachusetts has the highest per capita healthcare
costs in the country (over $9.000), a below average percentage of the
population that is uninsured, and a market that is overwhelming
dominated by non-profit insurers and hospitals.  Supposedly greedy for profit insurers and hospitals are simply not much of a factor in Massachusetts.

Within the last couple of days the Massachusetts health connector
website went live. People can key in their zip code, date of birth,
number of people to be covered, etc. and get rate quotes from four or
five different plans for each of four coverage levels – Bronze (both
with and without RX), Silver and Gold. Type in a Massachusetts zip code
and try it out. The website is: www.mahealthconnector.org.

 

In the comment thread on Andy Grove’s prescription for solving the healthcare crisis, Gregory Pawelski writes:

"It is entirely inappropriate to regard the randomized clinical trial as being the "gold standard" for judging whether a treatment does more good than harm. In life or death situations, one must make judgements based upon preponderance of available evidence as opposed to proof beyond reasonable doubt. It seems obvious that evidence-based medicine proponents may fail to apply this common sense standard on a consistent basis. "

In response to Beth Israel Deconess Medical Center CEO Paul Levy’s critical post on pay-for-performance plans, Mehul Dalal writes:

"We cannot talk about closing the income gap between the cognitive
and procedural specialties without mentioning the role of the Relative
Value Scale Update Committee (RUC). Their proceedings are opaque and
dominated by specialists and my understanding is that CMS adopts their
recommendations rather uncritically.

It seems that these proceedings should be more transparent and
perhaps an independent entity should ensure their recommendations are
aligned with the preferences of the beneficiaries. (this is public
money after all)."

PMH had this to say in the thread on the interview with MDVIP CEO Ed Goldman.

I attended a MDVIP kick-off last night. It was an older doctor (my
wife’s) who falls into the category of "frustrated over having too many
patients, wants a life." A lot of his patients seemed to be older and
probably have the money. Nobody walked out, and it was pretty well
received.

"Our pediatrician had booted the insurance companies before my kids became patients. Luckily, my family has been healthy. There have been a few emergency room visits over the years and one daughter went through a battery of allergy/asthma evaluations. While the cost of annual doctor’s visits has added up over the years, it was the testing, specialist, and emergency room visits that were by far the biggest hits. Insurance was applicable to those services.

The pediatrician seems to have been successful with his approach. His staff is small and he’s accessible, as well as being a good guy."

M.W. writes in to criticize Dr.Anna Pou’s supporters:

Having read many of the sympathetically concerned statements regarding the Dr. Anna Pou/Memorial Hospital Case, the majority positions of support, based either on personal character assessments or assumptions regarding professional competency, are sadly but well intentionally misplaced. The truth of the matter is that injections of combined drugs in conjunction with saline were administered to chronically ill elderly patients with the intent to humanely end life. Also, the supportive statements are unaware of the single 30ml immediate-release morphine sulfate bottle which plays an important but  ancillary role in this case.

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