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THCB Reader mail

Journalist Maggie Mahar, the author of "Money-Driven Medicine" and a
frequent contributor here at THCB, begs to differ with Matthew’s
lukewarm review of Sicko. (Theme: "Will Sicko Hurt more than it helps?") She emailed in to say:       

"I think that the movie will help push healthcare reform forward–in part because the filmis controversial … Focusing on the middle-class underinsured rather than the uninsured 
was, I think, a very shrewd move on Moore’s  part, and I don’t think the Cuban finale hurts him)." 

Skeptic disagrees about Moore’s picture. He had the following comment:

"Whether or not he realizes it, Moore has become a useful idiot for some
of the most reactionary interests in health care … I predict this film will be as effective in helping the
medically underserved as “Fahrenheit 911” was in preventing the
re-election of George Bush in 2004."

Peter Chowka, the author of an early review of Moore’s film in American Thinker ("Prepare to be sickened by Sicko"), that provoked a fair amount of heated discussion in the blogosphere obviously didn’t like the film very much. But he emailed in to say the following:

"My disagreements with Moore aside, I have to hand it to him for stoking
the discussion and debate about U.S. health care policy to
unprecedented levels, certainly a degree not seen since 1993-’94.
Hopefully, I (and I know many others) will have future opportunities to
delve more deeply into the core of the issues that Moore and his
supporters are highlighting, as the issues continue to emerge and, we
can hope, become more clearly defined."

Meanwhile, Mona writes in to tell us about OutofPocket.com, a start-up that seeks to use the power of social networking to shed light on
the weird world of health care pricing.

"I wanted to let you know about a grassroots
consumer initiative for consumers to look up true prices
for common health care services.  The website consists of
consumer-contributed data and CMS payment data for common Medicare
services.  As a consumer advocate, my goal is to achieve critical mass
for consumer participation in this initiative. I believe consumers have
the power to positively influence the future direction of healthcare
and encourage healthy competition in the industry.  In order to
accomplish this goal, we need your help promoting www.OutOfPocket.com to get the word out."

In response to last week’s THCB post on Los Angeles OB-GYN Dr. Gil Mileikowsky and his fight to win protections for doctors who report medical errors at their hospitals, Bart Lee of Spiegel, Liao & Kagay writes.

"John Irvine’s note is most welcome. We represented Dr. Mileikowsky. Charly Kagay of this office handled the appeal. Dr. Mileikowsky’s Black Box idea is a system of anonymous and objective review

Presently "Peer Review" as a discipline is all too often biased. These biases go largely uncorrected because of the immunity provisions of the Health Care Quality Improvement Act, which has not improved the quality of health care. There is a sword available, by a simple amendment, to untie this Gordian Knot: My suggestion, which follows, as to the best and quickest way to fix HCQIA’s immunity problem, is  … (Comment edited for length. See full version here.) …  to amend this section:

"A professional review body’s failure to meet the conditions described in this subsection shall, in itself, constitute failure to meet the standards of subsection (a)(3) of this section."

"That is, take out the "not." A hospital that that runs a kangaroo court should not get to take advantage of its own wrongdoing. Each and every National Practitioner Data Bank report that results from a peer review body that fails to meet the specified conditions should not be privileged, should be enjoin-able in equity in state or federal court, and should give rise to a damages action including attorneys’ fees. Each and every kangaroo court "peer review" should not enjoy immunity from any damages causes of action."

If you missed Dr. Mileikowsky’s original YouTube appearance, you can find it here … [Uber]

Dr. Thom writes in to opine on Maggie Mahar’s excellent essay – "Do Non-Profit Hospitals deserve their tax breaks?"   

"I am a for profit doctor with privileges at a not-for-profit institution.  I do my share of unassigned calls, see uninsured patients and I practice with the largest private provider of Medicaid services in my state.  When someone comes in for care and can’t pay, I charge him the full amount on the front end and mark down the charges or write it off completely on the back end.  Rarely do folks who can’t pay get sent to collections.   Our hospital, on the other hand, has what our consultants have told us as the most aggressive collection policy they have ever seen, profit or not."

Meanwhile, reader speculation that start-up social networking site PeerWisdom might be changing its name at some point soon turns out to have been exactly on target. The company’s Jude O’Reilly writes to us happily:

"As if on your cue, we’ve just announced the change of our name from PeerWisdom to Trusera. (We’re not giving up on being wise, just using wisdom in our name!)  PeerWisdom was intended to get us through our early funding." 

In response to Scott Shreeve’s post arguing that recent reports of the death of the consumer-driven-health care movement (gulp!) may be slightly exaggerated, B.E. Rodin writes:

"There are few other industries where information on product quality and cost are so difficult to obtain.  Of course, this is compounded by the third party payment system.  When someone else foots the bill, we have no motivation to efficiently spend limited dollars.  The second key ingredient in consumer driven health care is to have consumers be responsible for allocating limited funds to spend on their health care.  Perhaps consumers will then routinely question the effectiveness/necessity of medical treatments and look for alternatives.  Perhaps they will start to live a lifestyle which promotes health, rather than assume that there will be a pill to cure almost anything that goes wrong."

Chris Johnson writes to weigh in on the debate over the merits — and lack thereof — of health savings accounts.

"I’m a self-employed physician with an HSA, and even I have
trouble using the thing effectively. In spite of the inside knowledge I
have of the system, it’s just as hard for me to find out how much
things really cost as it is for anyone else."

Meanwhile, insurance agent Chris – presumably no relation – writes in on
the controversy surrounding the business practices and standards of certain health insurers.

"I’ve researched the Mega and Midwest plans and honestly cannot find
a lot of room for those companies to get out of paying what they say
they will. I think the problem is that agents tell people they have
more coverage than they actually have.  My personal experience has been
that I have NEVER been encouraged to make the plan appear better than
it actually is…" 

Continue reading…

QUALITY: Back surgery request

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. 

JOB POST: Practice Leader, Knowledge Services

Kaiser Permanente’s Care Management Institute (CMI) is a unique,
pioneering institution with a mandate to drive, fund, and catalyze care
management activities throughout our non-profit HMO. CMI strives "to
make the right thing easier to do. The Center for Health Care Delivery is creating a new Knowledge Service/Evidence unit. The Practice Leader, Knowledge Services will focus on Knowledge Services and guideline development. In conjunction with the CMI Manager, CMI Evidence Methodologist and Medical Director, Center for Health Care Delivery, this position initiates, coordinates, and facilitates the development, revision and dissemination of national evidence-based guidelines  designed to improve member outcomes and organizational performance throughout KP.Responses to: Ca**********@**.org.

PLEASE remember to include THCB JOB BOARD in the subject of your email.

Continue reading…

POLICY: Orszag makes the CBO get religion

Somehow last week in the midst of one of the busiest working months of my life I managed to squeeze in a little time with Peter Orszag who’s the new-ish Director of the Congressional Budget Office. Or as he called it the “soon to be Congressional Health Care Budget Office.” Peter is  a true convert to the cult of Wennberg, and so we had a real meeting of the minds. He has started telling his story to all who’ll listen, and given the power of the CBO in Washington, plenty of important people are listening.

Go read his testimony on health care and the budget (PDF) (similar html here) from earlier this week. Pay particular attention to the figures which you can click on directly in the PDF navigation menu—especially the charts on the variance in costs for Medicare recipients by region (#3) and the impact of the current trends on future Medicare costs (#4). If enough politicians pay attention, then the second biggest problem in health care (practice variation) might get addressed at the same time as the first (lack of universal coverage).

He’ll also be having the CBO in future produce some slightly more synopsized and bite-sized reports, but for now there’s more data on their web site and you can subscribe to RSS feeds of their latest reports. I feel a blog coming on….

Meanwhile it won’t surprise you to know that the first hearing on any comprehensive health care reform legislation since 22 June 1994 is happening tomorrow, when the Wyden bill gets a hearing before the Senate Budget committee. If you want a clue as to how it’ll go, the line up on the panel is Len Nichols, Ph.D., Director, Health Policy Program, New America Foundation; Sara R. Collins, Ph.D., Assistant Vice President, Program on the Future of Health Insurance, The Commonwealth Fund and Arnold Milstein, MD,Medical Director, Pacific Business Health Group.

Luckily there were no problems in the health care system between the end of 1994 and the middle of 2007, so it didn’t matter that Congress ignored the issue.

Thank God the lunatics have at least had their charge of that part of the asylum taken away…

POLICY: We want Moore…or something like that

John Cohn on Michael Moore–Fan-fucking-tastic. It’s called “Will Michael Moore’s Sicko help or hurt the universal health care movement?” Go read it.

Ezra Klein takes the wider view on Moore’s attack on American exceptionalism, equally worth it.

As for me, well over at Spot-on I manage to link Sicko with the other big release this week

Strange things are afoot in the normally rarefied world of health care
punditry. It’s going primetime. And I’m blaming Steve Jobs.

Come back here to comment.

POLICY: Why isn’t more being done about ASD? By John Whitmer

One in 150 children is diagnosed
today with Autism Spectrum Disorders (ASD).  ASD is a neurological
and immune deficiency disorder that affects people’s behavior, communication,
and socialization.  ASD is genetic—in other words, children are
born with ASD.  It is passed-down from parents, and siblings have
a greater chance of having ASD if another has it.  There are also
environmental triggers.  Symptoms of ASD closely resemble heavy
metal poisoning such as exposure to mercury.  There is no cure
for ASD, it is a life-long condition.  ASD is very difficult to
diagnose.  ASD is a spectrum of disorders, including specific diagnoses
of Autism, Asperger’s Syndrome, Rhetts Syndrome, Child Disintegrative
Disorder (CDD), and Pervasive Developmental Disorder-Not Otherwise Specified
(PDD-NOS).  No two people with Autism have exactly the same characteristics. 
Some have language, other do not.  Some with Asperger’s Syndrome
are brilliant; others have a comorbid diagnosis of mental retardation. 
Some will be fully included into school and work places; others will
always live at home or in institutions.  Skeptics emphasize the
difficulty in diagnosing ASD and changes to the classifications of diagnoses
as evidence of an overzealous culture and of inflated numbers. 
I should know, I was skeptical too.

But ASD is real.  I should
know, my son is the one in 150.   

Continue reading…

PHARMA/PHYSICIANS/HOSPITALS/QUALITY: Busy busy busy

My correspondents have sent me lots of articles today. All worth a read—

When Is a Pain Doctor a Drug Pusher? Basically never as far as I can tell but in the DEA’s view any time the DEA feels that its livelihood is threatened. What a disgusting scumbag organization (and I include the US and State DA’s in their ecosystem), and I’m beyond disgusted that as a taxpayer I’m paying for this insanity. The DEA needs to abolished and anyone who’s

Report Rates Hospitals on Their Heart Treatment. The “report” is from CMS using Medicare data and it names names. I spent the last two days with lots of hospitals. They don’t think this type of hospital ranking matters yet, and they’re right. But it will matter increasingly as patients figure this out (more from me on this next week).

 

3 drug makers busted and fined for drug reimbursement scam in cancer drugs. Not exactly a surprise:

The plaintiffs argued that the drug makers had sold medications to doctors at steep discounts to the “average wholesale price” that Medicare and pension funds paid, while secretly encouraging them to claim full reimbursement from insurers.

There is nothing rational about allowing doctors to profit from selling drugs. But then again there’s nothing rational in our payment system as a whole. This is, though, one abuse that should be ended quickly.

Finally from the WSJ, yet again showing that it’s a socialist rag, How many doctors does it treat to see a patient? (Behind sub wall I’m afraid), but let me give you the first few lines:

In the mid-1990s I worked weekend shifts as a “moonlighting” doctor in a suburban Chicago hospital. When I would show up on Friday evenings, the other doctors would always say: “Peter, remember, no roundtrips on weekends.” Translated, that meant no patients admitted over the weekend should go home before Monday afternoon at the earliest. I soon understood the genesis of the “no roundtrip” rule. At the crack of dawn on Monday mornings, before their regular office hours, the doctors would go from room to room, providing consultations and filling out billing cards.

The villain is of course fee-for-service medicine. The author wants it eliminated and he’s right. But note the interesting screw-up in the current incentives. The doctors wanted to see their patients on the Monday so they could bill FFS and make more money. But the hospital was getting a fixed DRG payment for most of those patients. It was in their interests to get them out of the hospital as soon as possible, as every moment they stayed they were making less money because they were filling a bed that could be filled with a new admission. Both of them are crazy incentives for the overall health care systems, but more than a decade later we still do not have hospitals and doctors on the same set of incentives—even irrational ones!

PODCAST/TECH: Interview with Isabel’s Joseph Britto and Jason MaudE

Over at the Worldhealthcareblog I have a video interview up with Joseph Britto and Jason Maude, the joint CEOs at Isabel Healthcare. Isabel is a very interesting company that uses natural language recognition to search clinical texts in order to help doctors make more accurate diagnosis. These are two very passionate and smart guys, and this interview tells you a lot about both their technology and how its application can improve health care.

HOSPITALS/POLICY: King-Drew and the wider issues of care for the poor

It looks like it might be the end for King Drew, or as it’s known now, King–Harbor. Some of the LA board of supervisors are in favor of closing the hospital immediately, and yesterday the State of California initiated proceedings to revoke its license. No one can pretend that this hasn’t been coming for quite some time.  A couple of years back, a long series in the LA Times found incredible graft, mismanagement, and corruption and appallingly poor care quality at King Drew. Given the hospital’s origins after the Watts riots of the 1960s, and its special place in the African-American downtown community, doing anything to King-Drew has always been politically charged issue. But after the recent incidents, particularly the one where the woman was left to die on the floor of the emergency department waiting room while nurses ignored her, and cleaning staff swept up around her, the hospital seems to have finally run out of defenders.

On the other hand, this is emblematic of a wider problem in American health care—how do you provide care to the poor in a system where there is no universal coverage or systemic primary care?  Bob Sillen, who now runs California’s prison health care system, but used to run Santa Clara Valley Medical Center used to remark that if there wasn’t a County Hospital in which to showcase how the poor were treated it would be impossible to get any attention on to the issue.

So it is my hope that as we enter a period of concern about the future of universal insurance coverage, we don’t abandon the extremely limited safety net that is in place for the poor while we all focus on fixing the wider systemic problems.

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