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POLICY/INTERNATIONAL: John Cohn puts the boot in….nicely

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I told John Cohn a while back that he was just too nice, and that he shouldn’t engage in the pointless argument with the free-marketeers about whether we treat cancer better or worse than the Europeans—especially as we do so much worse on many other measures. But John doesn’t listen to me—instead he takes the cancer argument and uses it to stamp all over the free-marketeers. At some point the referee should step in and stop this fight…

Meanwhile here’s the real problem. Next to John’s article on the CBS site is a video of Bush, and this is the text below it:

CBS News RAW: President Bush announced new proposals for the tax code intended to improve health care. His ideas counter Democratic proposals to nationalize the system.

Please could someone at CBS or anywhere else find me an example of a democrat wanting to “nationalize” the system. “Nationalize” means the government owning the production/service a la the Post Office or UK NHS. Not even Dennis Kucinich seems to be in favor of that. So what the hell are they talking about? I don’t know but neither do they. And, as they’re controlling a major news organization’s output, that is the problem.

QUALITY/INTERNATIONAL: A great check list and more about EBM

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Humphrey Taylor from Harris mentioned to me earlier this year that one thing Americans don’t realize is how much other health care systems are changing—while ours seems stuck in 1987. One case in major point is the UK where serious changes in terms of more money being spent on health care (a designed increase of nearly 2% of GDP), a reorganization of primary care called Primary Care Trusts, a major investment in IT for healthcare, and a significant change towards paying primary care docs for outcomes have all been going on in the last few years. In fact probably the most Americans realize about this is the scene in Sicko where the British GP discusses his salary (much higher than PCPs get in the US), shows off his fancy car and nice house, and explains that he gets paid more for keeping his patients healthy. All true and all recent phenomena.

Continue reading…

INTERNATIONAL: Ian Morrison vacationing at the taxpayer’s expense

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My old boss Ian Morrison has been in Australia studying the health care system. I’m sure this was a work visit for him with neither a bar nor a golf course in sight. He did though come back with a pretty interesting view of their changing system, called  Aussie, Aussie, Aussie which is basically a British style NHS with a robust private insurance sector layered on top of it.

The only thing I’m not so sure of is why the government—any government for that matter—would want to give people a tax break to buy private health insurance. (They do it in the UK too, BTW). Unless of course the politicians concerned planned to amakudari into private health plans later. Anyone looking at the US experience knows that exempting health insurance spending (and mortgage spending) from taxation means that we spend too much money on health care (and houses).  The only place I’ve ever seen that tax break successfully taken away was in the UK, where the tax break for mortgage payments was phased out in the late 1980s. Of course it didn’t stop house prices from going up there too, but there’s no need to encourage it.

Still in general, like the French, the Aussies have got to a mix that most Americans outside of the Cato Institute could probably live with. Pity we can’t have it here.

INTERNATIONAL/QUALITY: Reggie will be having a fit

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I’ve always been amused that the most cited example of the “focused factory” that Reggie Herzlinger perceives to be the answer to  medical cost and quality problems is the Shouldice Institute in Canada. That’s right the country where it takes ten months to get a doctors appointment if you’re pregnant, and where the state controls all health care—concepts Reggie’s not so keen on.

And of course the nearest thing to focused factories in the US are the specialty hospitals which—given our incentives—make most of their money increasing the amount of care given to a set populations (probably unnecessarily) and taking the most profitable cases away from the local community hospitals and away from their mission of care, or their fat endowments (Delete half the previous phrase based on your stance on the matter).

On the other hand if focused factories were established within a cost-constrained environment, presumably we’d get a clue as to whether they are more efficient and save money over all. Well maybe we’re going to find out.

Apparently London is going to be transformed into a city of 200 large multi-specialty group practices with what sounds like specialty hospitals to handle the acute care. This is going to be very interesting.

Meanwhile, in Southern California a doctor buys hospitals, kicks out managed care, jacks up prices and makes bank. Tthat’s real value add to the system

POLICY/INTERNATIONAL: The best health care system in the world!

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God Bless America.

Zeke Emmanuel is a pretty prominent ethicist and with my former economics teacher/prof Vic Fuchs author of a not bad proposal for universal health care. He’s more famous as the least famous Emmanuel brother—the one who’s not in The West Wing or Entourage. And he thinks that the health care system is a mess. Now you’d assume that if he was fired one of his two very, very rich brothers could step in to keep his family out of the workhouse. But apparently not.

President Bush frequently has said Americans have the world’s best health care system, but Emanuel stopped short of calling Bush clueless in his essay (behind JAMA firewall)and during an interview with The Associated Press. “I work for the federal government. You can’t possibly get me to make that statement,” Emanuel said in the interview.

But don’t worry, the AP found a rent-a-quote to make the article fair and balanced:

David Hogberg, senior policy analyst at the National Center for Public Policy Research, said a strong case can be made that the U.S. health care system is the best. “It depends on what measures you use,” Hogberg said. Life expectancy is influenced by many factors other than health care, he said, and nations measure infant death rates inconsistently. Other measures show the United States performing well, he said.

Just in case you wondered the National Center for Public Policy Research may sound like its some official well respected non-partisan body  but its header title describes it as a  “A Conservative Think Tank” (an oxymoron perhaps). Yeah, those guys know all about health care, I’m sure.

However the reason for this fuss is the latest edition of the Commonwealth Fund’s six-nations report. What does it say? Same thing it’s said for ages. (Shorter version here) The US system costs more and is no better—nay, it’s worse. But Karen Davis and pals have this little zinger in the tail

Findings in this report confirm many of the findings from the earlier two editions of “Mirror, Mirror”. The U.S. ranks last of six nations overall. As in the earlier editions, the U.S. ranks last on indicators of patient safety, efficiency, and equity. New Zealand, Australia, and the U.K. continue to demonstrate superior performance, with Germany joining their ranks of top performers. The U.S. is first on preventive care, and second only to Germany on waiting times for specialist care and non-emergency surgical care, but weak on access to needed services and ability to obtain prompt attention from physicians.

Did you notice that? We’re not even Number One in shortest waiting times for elective surgery. Want to get your hip replaced most quickly? Move to FrankFurt!! I assume that David Gratzer and Sally Pipes are brushing up on their Deutsch right now.

And in other news…apparently Michael Moore isn’t a thorough fact checking reporter and according to his supporters(!) leaves behind a “trail of broken promises to colleagues, exaggerations of facts, and footage used out of context.  Hmm, I’d never have guessed that (actually I’ve read one of his books and yup his “research” is incredibly sloppy. In fact so sloppy that apparently PhRMA and AHIP are on to him:

The Pharmaceutical Research and Manufacturers of America issued a statement attacking Moore’s record. "A review of America’s health care system should be balanced, thoughtful and well-researched," the statement said. "You won’t get that from Michael Moore.

And given the quality of “research” from those two organizations, do I have to add the next sentence for you?

PODCAST/TECH: Interview with Chris Hobson, Orion Health

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Since John Irvine’s taken over as the business lead for THCB, we now have a raft of new sponsors including CDW, Silverlink and now Orion Health. Apparently the marketing folks at Orion thought that it would be a good idea for me to interview their Chief Medical Officer Chris Hobson. What I didn’t realize is that Chris is a wealth of knowledge about health care systems around the world, and in particular how EMR use became prevalent–yup that essentially 100% adopted–in New Zealand We had a very interesting conversation about that, and if you’re as interested in that conundrum as you ought to be (which is very!) you need to read this. And hopefully the marketing people wont be too upset that their CMO barely got close to the topic of what OrionHealth actually does!

Matthew Holt:  This is Matthew Holt at The Health Care Blog and today I’m doing another podcast. And with me I have Chris Hobson. Chris is the Chief Medical Officer at Orion Health. I’m very happy to be talking to anyone at Orion Health because unbeknownst to me last week they have decided to become a sponsor of The Health Care Blog. As part of that arrangement, I’m very delighted to interview Chris because I interview a lot of people who do not sponsor me. [laughter] Anyway, Chris, good morning. Thank you very much for joining me. Thanks to Orion. I don’t know who was it who your organization who decided to do this as I am no longer the business rep of the Health Care Blog but delighted to talk to you.

Chris Hobson:  Good morning. It’s nice to be here.

Matthew:  I sense by your accent you are one of these American immigrants. Well, you’re in Canada, right?

Chris:  Yes, actually I’m native from New Zealand. Orion Health, actually, we started in New Zealand. As we’ve grown from New Zealand across UK, Canada, Australia, and other parts in the US, I’ve sort of tagged along with the company.

Matthew:  That’s great. Well, it’s always good for people to come from the rest of the English speaking world to tell the North Americans how to do it. I’ve been doing it for years, not that anyone is listening.

Chris:  [laughter]

Matthew:  Let’s talk a bit about that. There are a couple of things that Orion does. For those people who don’t know about Orion, and you’ll explain it better than I do, loosely you’re in the business of improving data communications and data integrations and that ends up being a lot around messaging and interoperability issue–currently a big picture problem in the US. But also elsewhere. Let me ask you to start with a couple of things. First off let’s talk a bit about what you perceive to be the big problem in the US in that sector. Because you guys are also in a lot of other countries, you mentioned New Zealand, UK, Canada and also some other European countries, give me a sense of. Is this the same problem everywhere in health systems or is the US unique?

Chris:  Sure. Well, we have our own perspective on what’s wrong with the health care system, but I guess, there would be fairly few people who would disagree a major problem with health care is the fragmented nature of it. There are a lot of different people, all well intentioned, doing a lot of good things across that the patients may interact with. The problems that we see arise as the result of all this—Going on from fragmented system to provider-to-provider-to-provider. In particular the information does not move along with the patient and it is very easy for the provider to focus on a narrow area and miss the big picture for what is going on with the patient.In the US, health care is more fragmented probably than anywhere else. In the sense that there are six thousand hospitals and just a huge range of both providers and payers. And if you look outside of the US, health care is not as fragmented; however, it is still quite fragmented and the same problems do arise.So if look for instance, the classic kind of story comes where down to and I’m taking this case from Don Berwick, and so I hope that’s OK but–

Matthew:  [laughter] We steal from Don Berwick all the time.

Chris:  [laughter] You steal from Don Berwick all the time. That’s great. He’s a Harvard professor of pediatrics, and his wife developed an obscure neurological complaint. It took some nearly six to twelve months before she got better more or less as a result, or not as a result, of the health care system. Along the way, she saw a huge range of different professionals who were all trying, well intentionedly trying, to help. The problem from his perspective was that each time they went to see a new professional he had to remember the case history. Each time they would see another professional, they would ask, "Tell me about what’s been going on." sort of thing. Of course, he had told the story so many times and been questioned about it so often that by the time he got to about 10 days or 10 weeks of this it was very hard to be strictly correct or accurate even with the best intentions.Another case in a sense that may be described as another sort of sense from when I was working at South Auckland in New Zealand, we went out and visited a home visiting nurse. And the first thing she said as she went in to visit a patient, she said, "Everything you tell me will be kept completely confidential, and I won’t share it with anyone." She then proceeded to take the whole history about what had been going on, and the patient had diabetes and had been to see a primary care practitioner who had said, "You have diabetes." But of course, the patient didn’t like that message particularly. So, he did nothing and a few months later he still wasn’t feeling very well, and went to see another practitioner who said ‘You’ve got diabetes’, and he didn’t like that story either. But eventually he managed to end up in the emergency room in the hospital and they looked up the history and said ‘You’ve got diabetes’. And they operated on the patient and then sent him out into the community. So when the community visiting nurse went to see the patient to look at the ulcer on the leg and dressings she knew nothing of all of this. Even though she worked for the same hospital and the same surgeons had done the surgery they hadn’t communicated onto the next provider what needed to be done.Now let’s rewrite that script and go back and say. The patient goes to see the first GP and he says you’ve got diabetes and the patient doesn’t like hearing that news so he goes to see the second practitioner. When he goes to the second practitioner, this time the stories different because he says ‘hey you’ve got diabetes, and by the way that first doctor that you didn’t like for telling you that you’ve got diabetes. He was right. You’ve got diabetes and now two of us have told you and you need to take this seriously.’ Let’s imagine the patient still did nothing and ended up in the hospital. The hospital specialist will say ‘You’ve got diabetes, and by the way, all these other people who’ve been telling you the same thing, it’s about time you started to take note of it.’So that’s a short vignette on what we see as the biggest problem in health care from our perspective. I mean health care is full of problems, but the information continuity and sharing of information, and sharing it in a way that improves the quality of care and re-enforces messages to the patient and it’s consistent. We see the lack of that as a huge barrier to improving the quality of care.

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INTERNATIONAL: Rationing American style

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I don’t approve of health care by anecdote, but there are plenty of loonies on the Canada bashing right who do. And some of them make movies to prove their point. I also think that taking individual stories out of context, compared to using data to describe the actual patterns of care, isn’t that valuable in an intellectual sense. But it sure seems to work in an emotive one.

But let me warn those aspiring Canada-basher film-makers. While you’re out raising your millions, certain pro-single payer groups here have beaten you to it. Apparently the bashers may not know this but there are both people who have problems south of the border, and others with video cameras who’ve met them. I’m awaiting the assurance that this is all the Canadians fault somehow.

The rest of you in the more rarefied crowd at THCB can go back to your regularly scheduled programming.

POLICY: Ezra Klein’s The Health of Nations

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Now I’ve met Ezra I can stop calling him the young punk. He has written another excellent review of health care in universal coverage nations, including socialized medicine in the heart of America for our allegedly most treasured citizens.

It’s called The Health of Nations. Go read it.

It’s not entirely without flaws, almost all to do with the lack of good recent data that’s a problem with these comparisons and a need to conserve space. He skips over the UK’s private insurance system which enables the rich to trade up for elective surgery, and the recent increases in spending under Blair which have enable the Brits to buy spare capacity in private countries, (and ramped up GPs pay!). It would be nice to have Ezra do something similar on Japan and Holland (although Japan looks something like Germany plus a Canadian fee schedule, and Holland looks like an Enthoven-wet dream).

What’s also to some extent missing is the changes that have happened recently. Humphrey Taylor remarked to me on Sunday that Americans dont realize how much other systems are changing as ours essentially never does. The Brits have gone to 30% P4P in primary care; the Dutch to individually purchased insurance in a managed competition framework; the Danes and the New Zealanders have added rapid deployment of IT (100% EMR use in ambulatory care); whereas the Australians have added a private top up layer over their traditional socialized  medicine system; the Swiss have their individual mandate.

Of course all of these systems have their problems and all are changing; we’re stuck in 1991. And in fact the VA system, although it works very well it about to be hit with a wave of Iraq war vets who have real problems–and is unlikely to get the resources it needs to deal with them.

And although it goes without saying to those in the know, we should keep repeating that this is the only system that visits not only ill health on the unlucky but often financial disaster too.

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