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TECH: FEMA and the Wisconsin CHIN — incompetence together?

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MrHISTalk had a little rant yesterday about the crappy demands from the Wisconsin Health Information Network that its users only use Internet Explorer.

User tip: those interoperability and open standards folks at the Wisconsin Health Information Exchange might want to get real web developers instead of the three doctors who appeared to have created their website (and who also run some for-profit ventures under the company name Asatte.) View it in a buggy, obsolete, and proprietary browser like Internet Explorer and it works. Try it with an open, standards-based browser like Firefox and you get this rude message: "Sorry, this page requires full support of modern browser functionality. Your browser does not support that functionality. Click here to get a current browser." Why would doctors waste time screwing around building websites when millions of Indians can do a far more professional job (and following international web standards) for $5 an hour? Even Asatte’s own site is hopelessly lip-locked onto Bill Gate’s buttocks, proudly proclaiming "Using XML to Office technology, Asatte allows authors and editors to use tools with which they are familiar, like Microsoft Word, to edit, maintain, and coordinate the creation of anything from small to massive publishing projects." Real programmers don’t "code" in Microsoft desktop applications (but doctors often do.)

But while we’re on FEMA’s case, its perhaps a little more serious that same thing is true for those people trying to use a non-IE browser while applying for disaster aid. I do though like the headline from the Good Morning Silicon Valley blog which reads, We’re a disaster agency; of course we use IE

On the other hand, I’ve sadly gone back to using IE since inexplicably a recent Firefox upgrade made it crawl on my machine.  And, now that I sometime use my GF’s Apple, am I alone in thinking that the usability of both Windows and Apple sucks, and that installing Linux didn’t seem to make things much better.

Isn’t it about time for some real innovation on (or maybe) off the desktop?

POLICY/POLITICS: A harrowing story from Katrina

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SignalHealth pointed the way to this story, which I’ve since found at another source by a couple of hotel guests who were basically imprisoned in New Orleans and not allowed to leave by the law enforcement and FEMA people who were supposed to be there to help them. Now before you take this entirely at face value, I’ve Googled a little bit, and found that the two authors of this account are San Francisco Paramedics who are very active in their SEIU chapter and were extremely anti-Bush, the military and police to start off with, and are posting this on an extreme left-wing (by my standards not by Fox News standards) web site.

But the problem with thinking that they’ve just made all this up is that it correlates with so much else that we know about what happened. Late on Thursday night on FOX NEWS (really!) Geraldo was in the Convention Center saying "just let these people walk out of there". They weren’t allowed to go. They were just left there. Even worse was reported by another Fox correspondent, Shepard Smith, about people just abandoned on the freeway. It seems very likely that the two SF Paramedics were among those out there. See this for the link to that piece of video.

I saw someone on CNN or MSNBC — a white man – telling his story about how the buses that they’d paid for had been commandeered (UPDATE: I’ve found the link the story about the buses for the hotel guests)– that matches the Paramedics story. This guy was taken out by a black man standing next to him, who’s name he didn’t know but whom he credited with saving his life. (UPDATE: And here’s another story from a St Louis lawyer that confirms the bus story AND the trapped on the freeway story)

Over at HIStalk, there’s a link to this incredible story about how three college kids took a whole SUV load of water and supplies into the Convention center TWICE before any real help got in there. And they had to smuggle their way in as "press".

When you start putting these pieces together, it’s clear that something went badly, badly wrong in our emergency preparedness, and how we responded to desperate people in our own country. The only people who emerge with any real credit seem to be the health care workers in the hospitals who kept their patients alive against the odds, and the people who went around the official channels to do what they could.

I would not have said anything other than on Saturday night at a dinner party, in so-called liberal San Francisco no less, one woman started explaining to us all that these were stupid people who should have a) left before the hurricane, and b) should have taken adequate supplies with them to the convention center and SuperDome, and c) were dumb and not like us because….well you can get the gist if I tell you that she was white, and in fact Irish. I lost it and pointed out that the English said exactly the same thing about the dumb starving ungrateful Irish in the potato famine. If you have time, read the whole history of that very sorry episode and weep.

I can think of no better riposte than to link to the greatest essay ever written on the topic. Go read it and marvel at how little distance we’ve come.

TECH: Foundation for eHealth Initiative in a smidgin of trouble

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You know, you try to help get this health care system IT stuff sorted out, you try to get people on one page on this eHealth BS, you get a little Federal money to try to get some of these projects off the ground…..and they want all this damn paperwork and are getting nasty about it.

The rest of you lining up to get your noses in the NHIN trough have been warned. Apparently our Federal government views paperwork as important and sloppy accounting as a bad thing. Unless of course it leads to a disaster so major that it decides to head up an independent investigation itself….

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

* * *

"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

* * *

"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.
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