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BLOGS/TECH: Brief musings on technology

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Just brief musings for Thursday, after I blew way too much time on the HillaryCare piece earlier this week at the neglect of paid employment….

Browsers: I have downloaded Firefox 1.0.6. You may recall that I went back to Internet Explorer after the Firefox 1.0.4 update slowed my surfing to a crawl despite everyone’s help. Well sad to say the 1.0.6 update doesn’t seem to have improved it at all….still way slower than Explorer. Explorer does suffer from more annoying pop-unders though. Any suggestions? Please put them in the comments.

Bloglines: I finally broke down and started using Bloglines. Actually I stole Enoch Choi’s Bloglines subscriptions, then kicked out the stuff that he likes and I don’t on Wine and Parenting, and added in my own stuff on Soccer and Politics….Thanks Enoch! Then I went through all his links and added a few of my own. Bloglines is far superior to My Yahoo as a usable user interface, and I am now more or less up to date on lots more blogs than I used to know about.

Links: Which leads me to another modest gripe. Because THCB has a reasonably good traffic (i.e. in the hundreds rather than in the tens) I have been getting lots of requests to share links. Some of them are dinged immediately because they are from online pharmacies, but many are from other good looking health and medical blogs. So as of today I’m putting out a new request. Please if you want me to link to you send a URL of your RSS feed which I cant stick in Bloglines. If I think that your site has legs over time and is worth a link (i.e. not in the first 2 weeks) then I’ll add it to the links as I get around to it occasionally — or when John explains to me how to add links in Typepad!

Devices and Security: Finally some substance from a blog which will definitely get a link when I get around to fixing my links. Medical Connectivity Consulting has an article about whether medical devices are regulated by HIPAA (and the answer is yes!). This is less obscure than it sounds, as the issue of security of medical devices is becoming a screaming big deal. I have heard 3 stories lately of entire hospital networks being infected by viruses that originated from medical devices like ultrasound machines.  These devices are often on the network, but the CIO’s team can’t do things like add virus protection software to them because the manufacturer claims they’re FDA regulated and can’t be touched. This hasn’t stopped them picking up viruses or being hacked via modem, and in one case the network was accessed via one such device and turned into a porn server. Tricky stuff and becoming more tricky as more devices become digitized.

POLICY: Data on abortion

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So the next Supreme Court justice has been announced and women’s right to choose about their own reproductive health will likely be substantially reduced, according to NARAL which really doesn’t like Roberts. Given that an interesting study was released today about the number of abortions in the US. The data shows that abortion rates fell dramatically over the 1990s.

In the year 2002, about 1.29 million women in the U.S. had abortions. In 1990, that number was 1.61 million…. for every 1,000 pregnancies that did not result in miscarriage in 2002, there were 242 abortions. This figure was 245 in 2000 and 280 in 1990.

In other words despite the rumor that abortions have gone up in number under Bush, they’ve stayed about the same overall (assuming a little population growth) and actually gone down per capita in the last few years — but not in a significant way. The really big change was from 1976 to 1990 when the numbers went up, then from 1990 to 2000 when the numbers went down.

I’m no expert on this issue and I tread very gingerly here, but doesn’t that at least somewhat imply that Clinton’s removal of the gag orders imposed by Reagan and Bush didn’t increase the number of abortions, but was some part of reducing them?

But the fact remains that some 20% of pregnancies end up in abortions. On a wider level that implies to me that we do a shitty job of helping women who don’t want to be pregnant from becoming pregnant. Given that we’re known how to do that since the 1960s, shouldn’t we be doing better?

Using these international data I found on this New Zealand government website, it seems that we are not doing as well as other countries in this aspect of our health care too.

Abortion ratios (abortions per 1,000 live births plus abortions) provide an alternative international comparison. The latest abortion ratio for New Zealand (223) is above that for Japan (217), and is lower than those for England and Wales (225), Australia (264), Canada (242), Sweden (258) and the United States (259). International comparisons are, however, affected by both coverage and laws relating to induced abortion. Consequently, the comparisons between New Zealand’s and other countries’ abortion experiences should be interpreted with caution.

Abortionrates

The chart above (purloined from this article from the British Medical Association) suggests that some countries have done better, and of course it’s no surprise that the Dutch who have full reproductive rights along with comprehensive sex education, come out on top.  Apart from of course the Irish, where abortion is illegal — so their numbers are probably pretty dubious.

But overall, no one is doing too well. We are sadly a long way from "safe, legal and rare" and likely to be further from there after last night’s decision.

POLICY/POLTICS: Why Hillarycare failed…and what we need to learn from that failure

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This is the continuation of an article I’ve threatened THCB readers with for some time about what in my view really happened the last time we got serious about health care reform.  And in it there are lessons for what we should do when the opportunity next comes up. (It’s also really long, so for the first time over here I’ve continued it “below the fold”)

There are lots of versions about what killed the 1993-4 health care reform effort.  Hillary Clinton has now decided that the problem was the lack of incrementalism in her plan.  Last week the New York Times said that since becoming a Senator:

She has deliberately avoided the major mistake she made as first lady, namely trying to sell an ambitious plan to a public with no appetite for radical change. <SNIP>. She summed up her approach in the first floor speech she delivered in the Senate about four years ago, when she unveiled a series of relatively modest health care initiatives. “I learned some valuable lessons about the legislative process, the importance of bipartisan cooperation and the wisdom of taking small steps to get a big job done,” she said, referring to the 1994 defeat of her health care plan.

On the other hand, some people are still claiming victory for the plan’s defeat even if they were at most modest bit players.  Here’s what one fawning bio says about former New York Lt Governor Betsy McCaughey

A 35-year-old senior fellow named Elizabeth McCaughey…wrote an article for The New Republic on what she discovered in a close reading of the 1,431-page document containing the Clinton Health Care Plan: Namely, that it would put every citizen in a single government-operated HMO. That one article shot down the entire blimp, and Betsy McCaughey became a 35-year-old Cinderella. One of the richest men in America chose her as his wife, and George Pataki made her lieutenant governor of New York.

Ignoring the fact that McCaughey spent her time thereafter putting poor New Yorkers into those HMOs she so despised, and then went off the deep end en route to divorce from Pataki, the rich guy, and reality (not necessarily in that order), it’s not really true that one article in The New Republic can be quite that influential. (Sorry Jon!).  Even if the overly geeky Clintonistas in the White House did feel that they had to come out with a point by point rebuttal. And anyway, the article only came out in January 1994 by which time the die was more or less cast the other way. Again we have to look elsewhere for the explanation.

If you want to go back and spend a few minutes wallowing in the era of trial balloons and secret task forces, there’s a very interesting time line of the whole process on the NPR website, as well as a briefer information over at the Clinton Health Plan Wikipedia site. It seems like there was a moment when it could have succeeded, and indeed there may well have been. What has been missing from the whole discussion over multiple blogs over the last couple of months has been the understanding that there’s a real world outside Washington and that sometimes (but not too often) what’s going on there has an impact inside the beltway.

Continue reading…

PHARMA/POLICY: Quick Plan B update with UPDATE

For those of you still playing along at home, it now looks like the FDA is going to make a final decision on the status of Plan B by September 1. So that should get us to a confirmation of Crawford as FDA Commissioner soon thereafter, although if Plan B is over-ruled I doubt whether the Democrats holding up the confirmation will be best pleased.

Meanwhile one of my dinner companions last night (can you guess the gender?) scoffed at the need for Plan B anyway, saying that if you just take 3-4 normal contraceptive pills it works exactly the same way. I timidly pointed out that if a woman had contraceptive pills lying around the house she probably wouldn’t need Plan B in the first place.

UPDATE: Late Monday Crawford was confirmed as commissioner.

POLICY/QUALITY: A good round up of lefty propaganda, and Berwick gets a gong

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The Christian Science Monitor has a quick diatribe on what a mess health care is, and how the HSA/CDHP movement will be a five to ten years distraction before we end up at some type of universal coverage/single payer.  The article is called Why the healthcare crisis won’t go away and is definitely worth a read as it pretty much encapsulates my views on the matter.

Meanwhile those of you who think that we need an Escape Fire will be amused to know that Don Berwick was given a Knighthood recently. Two quick explanations for you non-limeys. No he can’t call himself "Sir Donald" — you can only do that if you are a Brit (Hence "Sir" Bob Geldof isn’t).  Second, no it’s not in the least likely that the Queen picked him out of a line-up — these awards are nominated by the government, and its just an indication that the quality/pay-for-performance crowd have had quite a bit of influence across the pond.

PBMs: Just to keep you up to date, with UPDATE

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We haven’t heard much about the plans that will end up being the Medicare Part D quasi-PBMs. These are known in CMS-speak as the Participating Prescription Drug Plans [PDP], and they’re going to be selling plans/enrolling seniors and then administering their benefits similarly to the way that PBMs do it for the private sector now. The first enrollment date is November 15th. I looked diligently in this CMS document advising the plans but I couldn’t tell when the applications to qualify had to be in by, but suffice it to say that they are well under way and CMS will presumably soon be announcing which plan is up in which area when.

On the other hand if (as we can assume they will) the current PBMs get into this game, they may have to think twice about continuing some of their business practices. Caremark, for example, is facing even more whistleblower suits about reselling returned stock. Supposing that the Federal government is now the end customer, I suspect some clean up needs to go on across the PBM industry which has sailed very close to the legal wind in recent years and has several state AG suits in process to show for it.

UPDATE: Promoted from the comments, (thanks Matt!) Forbes ran an article last month that I missed on how and why the scams will increase as Medicare Part D takes shape. It’s really worth reading the whole thing. As my old boss Ian Morisson use to say, a claim is an agreement made between a doctor and a patient to defraud an insurer!

POLICY: New York Medicaid fraud

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While I’ve been ragging on Florida, the NY Times has noted something we’ve all known for a while — New York’s Medicaid fraud may reach into the billions. Given that New York’s Medicaid program spends more in total and way more per capita than California’s, the tricks going on within the system there have been going on a long time.

The Industry Veteran comments:

Of the $44.5 billion annually spent on the program, sources tell the Times that as much as 10% is diverted to fraud and abuse. I quote here what I consider to be the article’s key paragraph:

"The lax regulation of the program did not come about by chance. Doctors, hospitals, health care unions and drug companies have long resisted attempts to increase the policing of Medicaid. The pharmaceutical industry, which has spent millions of dollars annually on political contributions and lobbying in Albany, has defeated several attempts to limit the drugs covered by Medicaid; other states have saved hundreds of millions of dollars annually with such restrictions."

I can’t say that this is exactly surprising news and I eagerly look forward to indictments of numerous physicians, hospital administrators and pharmaceutical company vice-presidents. I have written before in THCB my opinion that a large percentage of physicians are amoral, sociopathic mafiosi who lack even the charm of a Tony Soprano. When these “made men” (and women) join forces with the truly narcissistic psychopaths who run our Big Pharma companies, corruption on a scale of the Tweed Ring remains inevitable. I can see why Frank Rich and others refer to the U.S. under George Bush as a new Gilded Age.

PHYSICIANS: Apparently Florida remains exceptional

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Why is there a nursing shortage in south Florida? Apparently it’s because the doctors are very badly behaved, sometimes.

The South Florida Hospital and Healthcare Association, seeking to recruit more nurses from other areas, organized focus groups of nurses who had moved here in the past two years and asked them what they didn’t like about South Florida. ”The No. 1 issue was physician abuse,” says Linda Quick, president of the group. ”Sometimes it was omission — the doctors didn’t engage them in the treatment process. But they also indicated there was hollering, yelling, sarcasm. They indicated it was a particular problem here,” compared to other places they had worked.

As ever Florida is just a strange place. We know their practice patterns are out of whack, we know that health care fraud and corruption is a greater problem there than elsewhere, and we know they can’t arrange elections …and left us with the hopeless bunch of clowns running the show now in charge.

I still think they should tow the whole state into the Caribbean and leave it there.

PHARMA/POLICY: Medicare Part D

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This is a complete cop-out as I’m still hacking away on my Hillarycare piece, and haven’t even read this, but the article in Health Affairs called Riding The Rollercoaster: The Ups And Downs In Out-Of-Pocket Spending Under The Standard Medicare Drug Benefit looks pretty interesting and I think suggests that we have an ongoing spending problem emerging in Part D even before it hits!.

Does one of my contributors care to read it and review? (email me for a Health Affairs pw if you haven’t got one)

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