Just when you thought you’d heard the last of it, Maggie Mahar, last seen over here abusing the health care system, pops up over at The American Prospect smacking down David Cutler’s study. Again well worth reading.
Above the Fold
PHARMA: Probably another false start from the DEA
The black stone that resides in the chest of DEA administrator Karen Tandy in the place where the rest of us have a heart must have some gravel chipping off today. The DEA allegedly has revised its rules on prescribing pain-killers:
Yesterday, DEA Administrator Karen Tandy said the agency had been wrong in limiting the multiple prescriptions and had made the tough decision to reverse course. She said the DEA received more than 600 comments from doctors, patients and others about its policies on narcotic pain killers, many of them strongly opposed to the agency’s position on limiting refills.
But basically this is a tiny move—allowing multiple prescription refills for those in chronic pain, but only by doctors who the DEA considers not to be in violation of their unwritten laws. After all, 2 years ago—right in the middle of William Hurwitz’s trial when his defense was about to introduce them—they introduced some similar guidelines they’d worked on with pain specialists for two years. So what happened then? Well given the choice of allowing rational behavior, even according to guidelines they developed and allegedly agreed with, and putting a doctor treating the chronically ill in jail. Guess which one they took?
The agency briefly posted the guidelines on its Web site in 2004 but then pulled them down and disavowed them.
Siobhan Reynolds from PRN is rightly, rightly suspicious
But Siobhan Reynolds, who created the Pain Relief Network several years ago to help defend pain doctors who she said were being unfairly arrested and prosecuted, disagreed and said the new DEA policy has changed little. "Ms. Tandy states here, as she has on many occasions, that doctors need not fear criminal prosecution as long as they practice medicine in conformity with what these drug cops think is ‘appropriate,’ " Reynolds said. "If that isn’t a threat, it will certainly pass for one within the thoroughly intimidated medical community.”
The story is that chronic pain is massively under-treated in this country, and opiates are the most effective way of dealing with that pain. Yet as I pointed out over at Spot-on the mad Calvinists who run our criminal justice system care not a whit.
TECH: Molly Coye is also an optimist
Managed Care has a conversation with Molly Coye about the progress in automating and infomating the health care system. You’d think she’d be a pessimist after all these years. But she’s not really! Well worth a read.
POLICY: Becker-Posner miss the point
And in, I hope, the last comment on the Cutler piece, two venerable Univ of Chicago economists debate it on their blog, the Becker-Posner Blog
Posner ascribes the problem of the high cost of adding a year of life to an elderly person to the desire of people near the end of life to spend whatever it takes to stay alive. Other than that’s not how people at the end of their life usually feel, the problem with these rational analyses is that they don’t understand how health care works. Decisions about end of life care are not made by patients–they are made by doctors and health care organizations. Wennberg’s work clearly shows that. The enormous practice variation in end of life care is a factor of cultural variation amongst physicians not one of patient choice—the patient don’t know about it. And it applies whatever the insurance status of the individual because it’s ingrained in local medical cultures.Other countries have got their physicians somehow to accept that (for instance) heart surgery or kidney dialysis on a 95 year old with a life expectancy of 6 months is not good medical practice. Here we routinely do it (as in Posner’s father’s case).Stopping that absurdity is the solution to our health care crisis as that’s where the vast majority of the unnecessary spending is. But to do that we have to change medical culture, and rather more difficultly, health care system incomes!
POLICY/THE INDUSTRY: Klepper is still an optimist
Nice short video from Brian Klepper on P4P. I think he’s optimistic, in that he thinks employers and the government will impose P4P on
providers. On the other hand the leading proponent of P4P in the government just quit! Then again Brian’s talking about slamming on the brakes or driving over the cliff, so maybe he’s a pessimist.
TECH/POLICY: A prime example of how health care works, sort of.
The continuing fuss about the Cutler article rumbles on. Here’s the Scientific American article that I’m quoted in. You’ll note that I may seem a little extreme (“rubbish”) but I was interviewed before I’d seen the article (or even knew that it was coming out!) and the reporter told me that the number for a year of life was between $100,000 and $200,000. But the question is still “worth it compared to spending the money on what else?”
Meanwhile the answer from David Henderson at Hoover (the guy I challenged on the local NPR call in show —on the MP3, my piece is cut out totally! The response is at 44.14) remains “we’ve picked the low hanging fruit, so it will be more expensive to move the needle as the years go by.” I wasn’t given the chance to say a) the industry has co-opted the government so it’s not like there’s a real “choice” in how we spend the money, and b) perhaps we’d get better value for money picking low hanging fruit in some other area of our society. In other words there are diminishing marginal returns from the flat of the curve medicine—so perhaps we should think of spending the money elsewhere? Meanwhile a few others have picked up on that. In the Huffington Post, Merrill Goonzer (yes that’s really a name!) from the Center for Science in the Public Interest points out the other part of the problem—“we may be paying for an Aston Martin but we’re getting a Ford”.
And when the status quo proponents say “costs are going up in other countries too” you can note that in 1970, health care costs in Canada and the US were the same as a share of GDP—and they’re not now! And in the 1990s both Japan and Canada reduced health care costs as a share of GDP. So societies can make choices about this, even if ours politically won’t. In fact in the last decade the Brits made a conscious choice to increase the amount of money they spend on health care—with some interesting consequences.
Of course the whole thing is totally bogus, as no one thinks of these things other than as ex-post facto justifications, and pretty weak ones at that. There’s a perfect example in the NY Times this morning. It says that Cardiologists Question the Risks in Using Drug-Coated Stents, a story that’s been reported on for a while, and includes a new Swiss study that says that only one in three cases is the use of the drug eluting stent correctly indicated.
Of course three years ago a Stanford health services research group suggested that stents as a whole weren’t worth it on a cost-benefit level, and got totally ignored other than on this blog! So there’s a chance (and it’s a slight chance) that medical counter indications might, just might, slow the spread of a technology that is basically unproven. There’s no chance that saying it’s not cost-effective will slow it at all.
Which kind of proves that arguing about the Cutler article is a waste of time!
TECH: Perot wins another big outsourcing contract
Catholic Healthcare Partners to outsource tech operations to Perot. Healthcare providers have been slow to outsource their tech operations, but Perot especially has been making some gains in recent years (while a few others have been stumbling).
HEALTH PLANS/POLICY: A health plan CEO who genuinely believes in universal coverage
Health Plan CEO Georganne Chapin believes managed care can evolve with universal coverage! I thought her money quote was pretty amusing.
So then, if Americans are interested in universal coverage, the industry supports it, and the money is already in the system, when will it happen? “In 1996, I said it would come in 10 years,” Chapin says. “We still have four more months.”
Of course she runs a non-profit Medicaid HMO, so her attitudes may not represent those of a typical AHIP member CEO!
POLICY: Starring on NPR
Not quite, but the local NPR station had a show on poverty, the middle class et al, and the TCS/Hoover /ExxonMobil representative David Henderson came out with the standard crap line about how we were getting more for our health care dollars. Given the recent Cutler piece I just had to pick up the phone and tell him that we weren’t. Unfortunately they cut me off before I had a chance to respond to his "well you go after the hanging fruit first so it’s bound to get more expensive" argument. He failed to note that there’s a point at which you stop going after the fruit well out of your reach, but that we live in a society in which the government has abdicated its fruit grabbing responsibility and has a allowed a system in which we bow down to the orchard owners and the companies who make ladders.
Meanwhile, his argument in favor of greater income inequality (which is what I originally called the show about) is that we have fluid classes so you’re not surveying the same people all the time…..sadly they’re not as fluid as they are in those stagnant European nations. But it sounds like Henderson got himself in the right class, and I guess it’s just tough luck on those who got themselves in the wrong one.
I’ll get the audio link up when it’s available….
QUALITY/TECH: Book reviews on quality and technology strategy
So it’s time for book reviews on THCB. The first book I will talk about is an excellent business written by — full disclosure — my good friend Tony Seba. For several years now Tony has been teaching a course on high-tech marketing strategy. I used to think this was just a chance for him to hang out at Stanford and spend some time in New Zealand, but in fact the course he has developed combines interesting and relevant business cases with general marketing lessons, and most importantly practical explanations of what to do about it if you are creating a business.Now Tony has put his course into a book, so you can get the benefit of his wisdom, without having to go to class. The book is called Winners Take All – The 9 Fundamental Rules of High Tech Strategy. I was really very surprised when I read it because the articles and examples that Tony brings up are things that may appear obvious. But from my time working in even small corporations, I know how hard it is for people to organize and coalesce around getting those things done. Tony’s basic thesis is that for most high-technology markets, one corporation tends to dominate an entire product line. Of course that is not a new theory, but what Tony has successfully done is to identify nine rules that allow companies and products which are in different parts of their life cycle to effectively dominate their markets.
What is particularly useful about the book, beyond the interesting stories and insight you will gain from reading it, is that there are practical ways in which you can put your own project. product or company within the context of the rules. Although Tony is concentrating on high-tech marketing, I think this has many applications for projects and products within the world of healthcare and healthcare technology. And of course any of those of you reading this who are thinking about developing new products for sale to the healthcare industry will have to take the marketing rules deeply to heart.
Interestingly enough, even though I’m pretty sure Tony could have got a standard publishing contract for his work, he decided to publish it at Lulu.com in what he calls a beta version. His argument is that it’s better to get the book out now and to get feedback and incorporate it into the rest of his course and his work, then to take on the traditional 18 months publishing process. But if you go and buy the book at Lulu, which I highly encourage, you won’t be able to tell any difference from a book you’d get in regular store (unless of course you choose to download the PDF version). So not only are you looking at the future of high-tech strategy, you are also looking at the future of publishing. Given that one of the industry’s that has been revolutionized by on demand online access to their product is low recording business, and it’s one that Tony featured in the book, I suspect that the publishing industry should be similarly concerned.
The other book I am reviewing is of a somewhat different flavor. It is one that has been advertising on THCB for the past couple of months, so I felt honor bound to take a quick read. The book is called On Track to Quality, written by James Todd, a professor of pediatrics at Denver Children’s Hospital. Essentially James has developed ten major rules around quality, many of which will be familiar to those of us who have tracked the quality movement in healthcare and outside in the past two decades. I was glad to see the pretty early on in the book he gone in favorable mentions to the greatest book about quality of all time, Robert Pirsig’s Zen and the Art of Motorcycle Maintenance, and in fact the style of Todd’s book reflects some of the qualities of that hippy classic. In the case of On Track to Quality instead of it largely being a discussion between a man, his alter ego and his son on a motorcycle journey, it is a discussion between a group of unlikely passengers on a snowbound train heading across the Rockies. However the passages include enough characters that one suspects that Todd has had some interesting beyond those one would normally associate with an academic pediatrician!
However when one strips away the somewhat stylized way that the material is presented, again in a fairly brief book — it’s just over a hundred pages -there is very useful information about what the quality movement is all about, and a holistic view of how it might be applied to medicine and healthcare. I particularly liked the way each chapter ends with a summary of the rule, and that you could build out the 10 rules and make them relevant to your own situation.
