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PHYSICIANS/POLICY: Another Podcast with Eric Novack

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So here’s another podcast recorded at the tail end of last week with me chatting with surgeon, talk radio host and "free-market" advocating surgeon Eric Novack. This one focuses on why health care costs so much and why we can’t stop physicians behaving badly. We discuss evidence-based medicine, managed care, capitation, end of life care, practice variation, and defensive medicine — and it’s still incredibly civilized. Don’t worry — we’ll keep having these talks until we really start laying into each other!

Here’s the MP3 to download (this one’s a little over 30 minutes listening time). Enjoy and please tell me what you think

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HOSPITALS/POLICY/INDUSTRY: Katrina and the response

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We have all been shaken by the devastation in New Orleans and the Gulf Coast. After a couple of days to reflect, three thoughts come to my mind. First has been the absolute heroism of health care workers in New Orleans, and those helping from neighboring areas. The tales of nurses, doctors and other workers keeping patients alive by hand-pumping ventilators, and performing near-miracles in conditions that none of them could have believed they’d ever have to work in reminds us that medicine and health care is a calling far more than just a job. Second, the time for investigations and blame if any will come later, but it’s beyond belief that it’s taken this long to get either food, water and medicine into New Orleans, or those stranded people out. Finally, it can’t have escaped anyone’s attention that the vast majority of those "left behind" are poor and African-American. And that’s a microcosm of what’s going on in our society and in our health care system. Hopefully this disaster may give us a chance to reflect on that and to make some changes.

I linked to the Red Cross earlier this week, but Instapundit has a long list of other charities who need help.

INTERNATIONAL: Medpundit in another foolish attack on the NHS

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It’s been a while since I took at look at what Syd has been saying over at Medpundit, but I picked up a couple of gems recently.  One gave Syd the chance to attack those damn socialists in the UK who apparently don’t do preventative screening the way she thinks they ought to. She manages to extract from an article in the Times which broadly agrees with the BMA’s criticism of whole-body scanning and other "excessive" screening, that the UK is not doing screening for diabetes and high cholesterol, (although she thinks that it must be somehow) and pretty soon that gets lumped into some random reader’s comment about having to wait 2 months in Canada for a diabetes test.

I know that these are just the random thoughts of a conservative doctor who hates socialized medicine, but Jeez, Syd–can you give it a rest for a second?

First, the really comprehensive study of primary care in five English speaking nations done last year did indeed show that the US did slightly better in preventative screening than the other nations, but it didn’t do that much better and on an absolute basis we’re not doing that well–(here’s the detailed chart). But overall we did pretty damn poorly in comparison to a bunch of health systems that spend a whole lot less money, including by the way in such measures as waiting times for primary care, coordination of care between doctors, and of course having the poorer among us to avoid necessary care because of the cost.  So taking one measure in isolation to bash the UK’s NHS and then to take one anecdote to extend that to Canada is just sloppy.

Secondly, there’s more to primary care than preventative screening–there’s treatment of the chronically ill. UK GPs are now actively compensated on the rates of their patients who get recommended treatments. We know from Beth McGlynn’s RAND study that only about half of American patients get the recommended treatment, so I’m prepared to bet that that number is now higher in the UK.

Thirdly I visited two GP practices in the UK early last year. Both were very typical and both did something that I suspect almost no American clinic can do. The first was able to tell me immediately how many of its patients were on certain drugs and be able to break that down by those patients’ demographic groups and health status. The second has a Wednesday each month when one afternoon was devoted to eye and feet exams for all its diabetic patients, who are called into the office when a nurse team checks them out. And because they had a functioning EMR, they knew who all the diabetics were. In the US we have a whole mini-industry that mines claims to try to find out who the diabetics in a health plan are, and I can assure that they can’t just call the doctor’s office up to find out–because no doctors office using a paper chart can possibly know.

Now to her credit, Syd has been putting in an EMR and she probably soon will be able to answer those types of questions, but she shouldn’t be quite so hasty in slagging off those Brits who’ve been showing us how it’s done just because she has an irrational fear of the socialized medicine bogey-man.

POLICY: Hilliard on Cato

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Over at SignalHealth Tom Hilliard has another interesting analysis of the Hilliard on Cato analysis of the Shadegg bill. He’s a bit too nice about Mark Pauly but otherwise it makes for combustible reading, and don’t miss the rebuttal comment from Cato’s Michael Cannon. I will be reviewing a copy of Cannon’s new book shortly, but head over to Signalhealth if you like this kind of policy wonk debate.

PHARMA: Blogging impact on pharma

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I will be speaking at a conference on Blogging and Pharma later this year.  More details here and there’ll be more about it on THCB soon. Meanwhile, do you think that this is the kind of story that pharma companies should be concerned about?  It never mentions the word lawsuit, but if SSRIs cause birth defects, how long before the Vioxx lawyers get ahold of this one and run with it?

It may be a while before we can be all grown up about our pills.

PHARMA/POLICY/POLITICS: FDA Official Quits Over Delay on Plan B, with UPDATE

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The FDA official in charge of women’s health quits over the delay on Plan B‘s approval. Well it’s good to see that some of the staffers left at FDA have some spine, because it’s clear that, whatever the lies being told by the Administration, this is all about cow-towing to the loonies on the Christian right rather than the science of the situation.

There are a couple of telling shots in the story. Crawford swore up and down that this was his decision and that it was a science-based one.  Not so. 

Susan F. Wood, assistant FDA commissioner for women’s health and director of the Office of Women’s Health, said she was leaving her position after five years because Commissioner Lester M. Crawford’s announcement Friday amounted to unwarranted interference in agency decision-making. "I can no longer serve as staff when scientific and clinical evidence, fully evaluated and recommended for approval by the professional staff here, has been overruled," she wrote in an e-mail to her staff and FDA colleagues"I can no longer serve as staff when scientific and clinical evidence, fully evaluated and recommended for approval by the professional staff here, has been overruled," she wrote in an e-mail to her staff and FDA colleagues.

Of course there were strenuous denials from all concerned, but what was she told?

Wood also said other FDA officials who are typically involved in important matters were kept in the dark about the contraceptive, called Plan B, until Crawford announced his decision, which she believed was made at higher levels in the administration. Wood said that when she asked a colleague in the commissioner’s office when the decision would be made, the answer was, "We’re still awaiting a decision from above; it hasn’t come down yet."

So you could argue that this was not Crawford doing what he thought the loonies wanted him to do, but instead he was actually taking instructions from Leavitt or Rove or whomever.  On this issue  they can send a sop to their "social conservative" friends. After all it’s only a small pharma company they’re pissing off here, not a big one, Just as well Lipitor doesn’t impact birth control, eh?

Meanwhile, there’s just a delicious piece of doublespeak from Leavitt that really outdoes some of the stuff we’ve had to put with from Rumsfeld over the years:

Many supporters of the Plan B application — including Sens. Hillary Rodham Clinton (D-N.Y.) and Patty Murray (D-Wash.) — accused Crawford of making a political decision that ignored science and public health. The two senators were especially angry at Crawford’s ruling because they had lifted a hold on his pending nomination based on promises, relayed by HHS Secretary Mike Leavitt, that the Plan B issue would be resolved by Sept. 1.

Clinton and Murray have accused the administration of breaking its promise, but Leavitt has disagreed. "The commitment was they would act," he told Reuters on Monday. "Sometimes action isn’t always yes and no. Sometimes it requires additional thought.

So now when you’re asked by your wife, boss, teacher, whomever why you haven’t done something you were supposed to have done (you know, "taken action") you can tell them that you were thinking about it and that is exactly the same thing! Not only that — it’s now official policy in what passes for the circus we call a government.

UPDATE: Bob Steeves points me to this quote from the spokesman for Mike Enzi (a Senator with an "R" after his name), showing that he didn’t get the Talking Points on this one and looks a little pissed:

Sen. Michael B. Enzi (R-Wyo.), chairman of the Health, Education, Labor and Pensions Committee, is considering whether to hold hearings on the FDA’s handling of Plan B, said spokesman Craig Orfield. Enzi had expected "a firm decision" from the FDA, not further delays, Orfield said.

CONSUMERS: Trade up players, but maybe not enough of them

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Once again there’s something very important in a WSJ/Harris poll which concentrates on the people that, when I was at Harris, were called the "Trade up players". These are the people with enough discretionary income to buy themselves a better class of service from their providers.  As I know many of you don’t have WSJ access, I’ve quoted most all of the results.

"Do you have health insurance? It could be from an employer, that you purchase yourself or from a government program like Medicare or Medicaid?"

Base: All Adults

Yes, have health insurance 87%
No, do not have health insurance 13

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"Which one of these statements best describes you?"

Base: Adults with health insurance

Total
I only go to doctors that accept my health insurance 85%
I sometimes go to doctors who don’t accept my health insurance 15

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"Whether or not you have done so in the past, how willing would you be to go to a doctor who doesn’t take your health insurance if he or she was highly recommended by a source that you trust?"

Chart1

"How willing would you be to pay the full cost of a doctor’s visit – rather than use your health insurance – if you . . .?"

Chart2

The important issue is that pretty uniformly, those with incomes over 50K, which is a little over average household income and around US median income, are willing to spend more money to get a better class of service. Obviously this means a couple of things

a) If you are marketing a health care service to wealthier Americans there is a willingness to pay for it. Of course that’s a well known fact to chiropractors, orthodontists, and cosmetic surgeons. But it might mean that other physicians and providers might start to think about providing better access and customer service, for a small fee (and I don’t mean insisting on $20,000 for concierge service). This is the Nordstroms approach, and one that health care providers should be thinking about emulating (and one that some are).

b) This willingness to pay is a minority effect — it’s a big minority and may be a majority in the case of referrals from someone the patient trusts.  But for most of these services more people are unwilling to pay extra, and of course large majorities of those with lower incomes, even those with health insurance, do not want to pay extra.

This tells me that continued bifurcation is likely to be the case when people seek health services that they have to pay out of pocket for, with roughly double the number who want to "trade up" skimping on "extras". Why does this matter?  Because in our brave new consumer world, cash may be an increasingly important way that patients pay for health care, especially for "minor" care out of their HSAs. So this correlates with much other data about user fees at the point of care–they tend to prevent lower income people from getting care (including often needed care).

Like it or not, we are slowly heading towards this future.  Unless, that is, you live in Rochester New York.

Meanwhile, (and this is a bit of a throwaway for Ron) the Kaiser Network Health Policy Report notes that the CBO is out with a study showing that "Uninsured workers are unlikely to purchase individual health insurance, regardless of whether they receive tax credits or other subsidies to help cover the cost of premiums, according to a report released on Friday by the Congressional Budget Office". Proving to my mind once again that high deductible health plans are not going to solve the uninsurance problem and that voluntary universal health care is a myth.

POLICY: Getting transparency in benefit costs, by Eric Novack

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After his first post on how to get doctors to provide care to uninsured patients, surgeon, talkshow host and THCB podcast star Eric Novack is back with a second installment. And believe it or not I completely agree with him. Here’s Eric:
I want to introduce another component of an incremental approach to health care transformation.  Many of you will wonder why it even qualifies as a reform- it does not require legislation, does not redistribute, reclassify, or create.  But let’s summarize the last post and the very insightful and valuable comments:
  1. People who can demonstrate financial hardship can go to the doctor for care- at no charge to them. Doctors would get a tax credit for a predetermined value (e.g.. Medicare rate) of the services. Those who deliver care are given incentives to provide care to those who would otherwise feel inhibited to seek care. (see prev. post for more)

The next component:  Require that employee tax statements (W-2) include the amount that employers spend on health benefits.
Employers understand that employee compensation includes benefits.  As health care costs have soared, costs to employers have soared as well. For example, someone earning $30,000 a year in salary sees that number on the W-2. Employers, on their tax returns, list employee health benefits as a line item, because that amount is tax deductible (a topic worth several radio programs and many blogs in its own right…)
The employee is ‘blind’ to this exact cost. If the cost for an employee was listed, employers could demonstrate how much money the employee actually receives directly and indirectly. In the example, let’s make health benefits cost $5000. Now, the W-2 would have $35,000 as the total compensation, but $5000 would appear as a line item for ‘health benefits’, which would be subtracted for tax purposes.
One of the many fears about HSAs and CDHP is that costs will just be shifted — or, put another way — companies will add to their profits at the direct expense of employees. Since we know that HSA prices actually decreased (eHealthinsurance.com data), if companies are forced to be transparent to employees about healthcare costs, it will be much more difficult to ‘reduce compensation’, as opposed to using the savings to fund the HSA savings accounts.
A win for transparency, corporate oversight, and the promotion of CDHC.

BLOGS/PHARMA: John Mack on “ethical pharmaceutical marketing”

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John Mack attributes one of my contributors words to me.  So first some remedial education.  When I say that this is The Industry Veteran’s views on XYZ, and here are The Veteran’s words, and I introduce that in an indented paragraph,  I mean that a guy calling himself The Industry Veteran wrote it and he is NOT me.  If an article appears here without such a paragraph you can assume that I wrote it. Sorry to be pedantic, but my desire to have differing view-points up here why this is called The Health Care Blog and not Matthew Holt shoots his mouth off about health care. It’s the same theory as the New York Times having  Paul Krugman and David Brooks both writing op-eds. I have enough opinions of my own without wishing to have other people’s attributed to me–even if I agree! And just to prove it I’ll have another article from Eric Novack up here very soon..

Meanwhile, what John has to say about the Veteran’s words is pretty interesting.  He notes that the tone set by pharma comes from the top, and I think that the Veteran would agree.

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