THCB

Categories

Above the Fold

BLOGS: Other stuff that’s worth a look

Between the back and forth with Medpundit and the DSM stuff I’ve had to be all too brief on some other great stuff. But it’s worth taking a look at

    • Dr. Ron Grelsamer’s new Knee Hip Pain Blog, which has a wryly amusing look at how surgeons (try to) deal with insurers
    • The new libertarian HC Blog, isemmelweis written by Trapper, a young but sadly all too experienced patient. Like the rest of the health care libertarians it’s nuts highly theoretical and impractical, but it is interestingly so.
    • Don Berwick likes what he sees about the UK’s NHS and its attempt to improve quality.

Note to self–I have too much in the hopper at the moment, but hopefully will get back to these issues soon. Also have to deal with the new cancer treatment scenarios, the recent study on EMRs and finally, finally, must finish my piece on King/Drew.

POLICY: Medpundit totally misreads the euthanasia debate in Europe, and is incredibly insulting to boot.

I tread gently around criticizing Sydney at Medpundit because her blog is so good even if her politics are increasingly "out of the mainstream" and the evidence she uses to support them is often incomplete, nay baffling. (See this piece reviewed by Ross on how Kerry planned to put everyone into Medicaid, although her argument rested on the ridiculous assumption that all employers would simply stop offering health benefits if Medicaid eligibility were expanded–even though there’s nothing stopping them from dropping benefits now, theoretically).

But in her Tech Central Station piece on the euthanasia issue in the Netherlands she has crossed the line and needs to be repudiated. The issue is that some Dutch doctors have decided after consultation with parents and the judiciary to euthanize terminally-ill babies rather than withdraw care and feeding and have them starve to death. It seems to be done with the utmost care and sensitivity:

"It is for very sad cases," said a hospital spokesman, who declined to be identified. "After years of discussions, we made our own protocol to cover the small number of infants born with such severe disabilities that doctors can see they have extreme pain and no hope for life. Our estimate is that it will not be used but 10 to 15 times a year."A parent’s role is limited under the protocol. While experts and critics familiar with the policy said a parent’s wishes to let a child live or die naturally most likely would be considered, they note that the decision must be professional, so rests with doctors. The protocol was written by hospital doctors and officials, with help from Dutch prosecutors. It’s being studied by lawmakers as potential law. Under the protocol, assisted infant deaths are investigated, but so far all of them have been determined to have been in the patients’ best interests.

Both the Dutch and philosopher Peter Singer feel that their actions are morally similar to abortion when a foetus has no hope for life. No doubt Syd disagrees with this, and probably (although I don’t know) with the legality of abortion too. Many who share her views on that also disagree with contraception, and even male masturbation as depriving the possibility of life (for a lot more on the social repression of masturbation up to the firing of Jocelyn Elders for mentioning it see here, but be warned there are some graphic pictures).

Disagreement over these issues is bound to happen and be controversial. However, Sydney goes on in her article to equate the behavior of the Dutch doctors, judges and parents as being the moral equivalent of the people who have committed genocide in Germany, the former Yugoslavia and the Sudan. That is a reprehensible thing to say. And there is a shiningly clear difference. The people in the Netherlands are clearly trying to do what they believe to the best thing for the children concerned. Syd may not agree that what they did was in the best interests of the children, but that is what the Dutch believe. I don’t know if Syd approves of the conventional treatment here of withdrawing food and care and allowing terminally ill kids to starve to death, but to me morally they amount to the same thing. Coincidentally, this week’s Pediatrics journal has an article on Do Not Resucitate orders for children undergoing surgery, which included a survey of pediatric surgeons and anesthesiologists. It finds that:

The majority of anesthesiologists (86%) and surgeons (94.7%) were willing to withdraw life support at the request of the family a few days after surgery if a child suffered an arrest in the operating room, was resuscitated, and had an adverse change in quality of life. The majority of anesthesiologists (55.1%) felt that the perioperative period ended when the child left the recovery room, with only 38.2% of surgeons agreeing (P = .0037). Many anesthesiologists (22.4%) and surgeons (39.5%) felt that the perioperative period should be extended until 24 hours after surgery.

Given that withdrawing life support means that the terminally ill child will die, there’s logically little difference between this and the direct euthanizing that’s happening in a few cases in the Netherlands. I’d argue that there’s no real "slope" whether slippery or not between these actions but there is a vast series of huge steps down to genocide. And logically if that’s the case then Sydney’s accusing the vast majority of physicians in this survey of being on the same moral stature as those involved in genocide.

That type of accusation has no place in our relatively civilized corner of the blogosphere, and if Syd won’t make that clear, the rest of us have a responsibility to call her out on it.

PHARMA: Overdosed America’s Abramson on CSPAN

John Abramson MD has an excellent book out called Overdosed America in which he criticizes pharma, the FDA and the medical journals for, at the least, bending the truth. To get a flavor of it, read the piece he wrote for TCHB last month. To get a bigger flavor of it those of you with no lives can watch his talk on C-SPAN on Sunday at 5pm–presumably the rest of you have Tivo!

Meanwhile, the final part on the Drew/King story has been bumped till Monday. Sorry to those of you waiting for it!

QUALITY: Medicare DSM demos are awarded, but not to providers

So the Medicare CCIP (chronic care improvement program) demonstration projects have been awarded and announced. And the winners are health plans and DSM companies. The plans are Aetna, Cigna, Humana, & United. The DSM companies are the more or less usual suspects of American Healthways, Lifemasters, Mckesson Health Solutions, Health Dialog (supported by a cast of thousands including Health Hero) and the slightly less well-known (i.e. I’d never heard of them!) XLHealth–which I guess specializes in obesity management.

What’s actually going to happen will be pretty darned interesting:

Phase I CCIP programs will serve 150,000 to 300,000 Medicare beneficiaries who are enrolled in traditional fee-for-service Medicare and who have multiple chronic conditions…. Beneficiary participation is completely voluntary and at no charge to beneficiaries and will not affect their ability to choose their own doctors and other health care providers…… Using historical claims data, CMS will identify beneficiaries by geographic area and screen them for CCIP eligibility. Targeted beneficiaries will be assigned randomly to either an intervention group or a control group.

Enrollment is voluntary and the organizations running the project will have to do the marketing/enrollment. What will they do after that?

Each of the local CCIPs will offer self-care guidance and support to chronically ill Medicare beneficiaries to help them manage their health, adhere to their physicians’ plans of care, and ensure that they seek and obtain the medical care and Medicare-covered benefits that they need. The programs will include collaboration with participants’ health care providers to enhance communication of relevant clinical information. The programs are intended to help increase adherence to evidence-based care, reduce unnecessary hospital stays and emergency room visits, and help participants avoid costly and debilitating complications.

The economics is that the sponsoring CCIP organization has to show at least a 5% reduction in the cost of these chronically ill seniors compared to the control groups, and then they get to keep the difference if they make bigger savings. This should be doable in that apparently in their commercial populations the DSM companies have been saving close to 15% compared to comparable cohorts. The question of course is, can the models that have shown success with a commercial population be translated to an older and potentially sicker one? And can it be done in places where there’s limited experience in care management?

Apparently the CCIP contracts couldn’t go to states which had big demonstration projects already, which included California and Texas, which is one reason that they ended up in states which, to put it one way, are not particularly known for innovation in population care management. (I hope I didn’t offend too many of my fans in Mississippi or Tennessee with that statement).

However, it’s worth thinking for second about who isn’t on that winners list. Remember the comment over on the DM Forum a while back about the DM executive explaining it at a cocktail party and being asked "isn’t that what doctors do?" Well there ain’t no providers on the list, and apparently not too many tried to get on it. At least one commentator, Robert Berenson from the Urban Institute, has pointed out that the way the law was written made it close to impossible for providers to take part. He doesn’t exactly pussy-foot around:

Consistent with the overall philosophy of the MMA, the law’s approach to addressing the growing need for improved care for those with chronic health conditions is a corporate one, focused on providing contracts to third party vendors, rather than enabling professionals to better serve their patients. Medicare has an important opportunity to lead the restructuring of how physicians organize and deliver health services, as called for by the Institute of Medicine in their seminal Quality Chasm report Instead, the MME would have Medicare merely follow private sector approaches that may not be well suited to the Medicare population.

Now there are some other approaches that Medicare has taken in smaller demonstration projects that have been more physician and provider-friendly, but they haven’t always had success. In fact one demonstration project in Washington state failed over physician lack of involvement earlier this year. And realistically, the current market attitude of hospitals which are focused on–and make their money from–acute care interventions, and the disaggregated nature of the physician population, overall makes provider organizations poor candidates for developing these CCIPs. However, that’s not the case for all providers. There are plenty of medical groups and forward-thinking hospitals that could have put such a plan together–after all it was big medical groups like Kaiser Permanente and the old Friendly Hills and Mullikin groups in S. Cal which started effectively innovating in the care of seniors back in the 1990s.

While CMS hasn’t said which bids didn’t get selected, either they didn’t pick a provider group or the whole thing was framed in a way that no provider group applied. Given that the intention of this demonstration project is to help reform Medicare, you’d think that one or two of the contracts could have been given to provider organizations to see if there’s any hope of innovation there. After all they’re the organizations that are going to have to change if we’re going to rescue Medicare in the long run. And one provider group, run by government bureaucrats no less, has quite an impressive record in DSM–so it’s a bit early to not even allow another one to give it a go.

Of course there is a somewhat more cynical view to take of this announcement. This Administration has shown complete faith in the market, even to the extent of subsidizing private plans to take over market share from the more efficient government Medicare plan–at an incremental cost to the tax payer. If you extrapolate out from current trends, Medicare will be costing in the order of 157% of GDP by 2020 (OK, not quite that much, but a very big number). To get Medicare costs under control, the only real long-term option is to pay the providers less. Meanwhile the consumers will want the same amount of services (or probably more). The conspiracy theorists amongst us might suspect that the way an Administration infused with market ideology will cut the spending on and benefits delivered by such a popular government program is to have private sector actors do the work for them. And if most of the new Medicare population is forced into private Medicare Advantage plans to get the best deal on the new drug benefit, and many of the most expensive patients are in CCIPs also run by private plans and their sub-contractors, it’s quite possible that the government can use them to beat up on the providers the same way that the employers used the HMOs to do it in the commercial sector 10 years ago.

POLITICS/TECHNOLOGY: A photo essay of unnecessary carnage

The war in Iraq recently passed another grim milestone. 1,000 Americans have died in combat. Many of them are national guardsmen who joined up for the college money. Had they been told that they had a good chance of going half way around the world at extremely high risk, you can be sure that many of them wouldn’t have enrolled. A very sad example of that is described in this heart-rending column from N. Dakota and it’s a devastating read.

It goes without saying that this was a manufactured and unnecessary war/occupation, which made us less safe at home and gave a great boost to Islamo-theocratic fascists abroad. Few people have been allowed direct access to the architects of the war and Kerry decided not to take the meager chances he was given to confront Bush, but today some direct criticism was aimed by fighting men stationed in Kuwait to Rumsfeld, to the cheers of their fellow watching troops. According to the ones on the ground, American troops need to dig in land-fill to get scrap metal to use as armor for their trucks. Rumsfeld basically said "screw you" to the troops and told them that "we go to war with the army that we have". So much for all that neo-con false patriot BS about supporting the troops. Rumsfeld doesn’t have to go to war himself and he’s been in charge of getting the troops the right stuff for nearly four years. It’s three years and 10 months since the first cabinet meeting when invading Iraq was put on the Administration’s agenda. Four years, by the way, is longer than the US was fighting in WWII.

Why am I raising this in a health care blog? Partly because the cost of this war taxes not only our humanity, but it also limits our ability to do things at home–the $150bn a year we’re spending in Iraq could have supplied universal health insurance to al Americans by any measure. But also today the New England Journal of Medicine came out with a photo essay to remind us that many of those wounded would have died in earlier wars–we’re just getting very good at saving people. But those soldiers have to live with their injuries for the rest of their lives. And of course multiply this carnage out some five to ten times on the Iraqi side.

The NEJM will doubtless be lambasted by the wingnuts (and some medbloggers) for running this piece. But until the horror of war is brought home to all of us, including NEJM reading physicians who are influential in their communities, then the chances of this occupation ending are slim. Sadly Iraq will continue on into civil war, with or without us.

And more scenes like this will continue, even if no one seems able to plausibly explain what this war is about. (Photos and captions are copied from the NEJM site). I only slightly apologize if anyone is offended.


A common type of injury associated with roadside improvised explosive device run over by a Humvee.


Damage-control laparotomy with temporary abdominal closure

HOSPITALS; King/Drew–putting a failure in context. Part 1

Today’s fourth of five pieces in the LA Times on King/Drew medical center is called How whole departments fail a hospital’s patients and it’s probably the most horrific of the series so far. It starts with the widely reported case of the nurse who turned off the alarms in the ICU and goes onto the pharmacy where one tech worked unsupervised and another stole prescription drugs in bulk to sell out of his garage, to the orthopedic unit where the two most senior physicians were eventually forced out because of gross irregularities that appears to be outright fraud, and even to the family practice resident who preyed sexually on patients and eventually murdered one. Previous articles in this series have followed doctors around and found that they appeared more or less when they like, but were clocked in for time they were not at work, and showed that the funding for the hospitals and its associated residency programs has been far more than for comparable public hospitals in California.

To put it mildly, this hospital has failed in its mission. But there is one thing that is barely mentioned in the article and it’s the extremely contentious issue of race. King/Drew was formed out of result of the Watts riots in the 1960s, and was designed to be the pinnacle of inner city health care. This hidden implication is that the race issue really matters, with the implication that this would have never been allowed to happen at a predominantly white suburban hospital. Beyond that the tone of the LA Times articles seems to me to reflect another view, which is that poor, urban minorities are unable to run a hospital properly. This is never expressed clearly in these articles but it seems to be hinted at in the background. Conversely the first article in the series quotes a black physician squarely accusing the LA County Board of Supervisors of racism for treating the hospital unfairly:

"We see something that we fought really hard for," said Dr. Herbert Avery, 71, an obstetrician who helped plan the hospital and served briefly on its staff. "And now it’s being driven down under the ground under the guise that the people out there … they’re black and Mexican and they’re too stupid to run a hospital and a medical school."

It’s obviously beyond the scope of THCB to get into the weeds of what’s wrong at King/Drew and make suggestions as to how to fix it, but given that most of my readers will be as appalled as the LA Times readers about what’s going on there, I want to give a little context as to why it’s so difficult to change the culture. I don’t think that race per se is at the basis of the problem, whether it’s issues between blacks and latinos (as has often been cited at King/Drew) or whites and minorities. It seems to me that an obsession with race seems to be missing some vital points about American society that are ending up reflected in things like the failure of King/Drew.

These group under three predominant areas. 1) the scale of inner-city poverty and its impact on health care. 2) the relationship between community and authority. 3) The management of a large scale health care systems in a world of electoral machines.

More on this in Part 2.

TECHNOLOGY: J&J continues winning diversification strategy

Unfortunately this stock picker wasn’t paying much attention, but there were some signs that this would happen. Last week a Prudential analyst thought that Guidant was the top pick in medical devices, while the NY Times had a story late last week that Guidant had no clear succession plan. (Hint, hint–if no internal successor, perhaps an external one would impose itself!) And now comes today’s news that J&J is going to buy Guidant (or at least is in talks to buy it). The price mentioned in the article is $24 billion, or about $3 billion more than Guidant’ closing stock price of $68. So if it goes through as is we can expect a price of about $75, or exactly where the Prudential analyst forecast. Perhaps we should pay them more attention in the future.

Where does that leave the device business? Guidant is big in bare-metal stents and has a new drug eluting stent coming out in 2007. It is better know for its defribillators in which its a strong second to Medtronic. J&J is strong in stents but needs to get stronger to combat Boston Scientific, and the defribillator business helps it broaden its dependence on some pharma products that will be coming under competition (like is anit-anemia drug Procit).

J&J has always managed to keep its diversified portfolio of companies more or less happily under one corporate organization. mMost other big pharma have basically relied on their dominant therapeutic areas and have treated their other units like the poor relations. For instance SKB’s role in consumer products was never as successful or as central as J&Js, while Pfizer and BMS have in recent memory sold medical devices business because they weren’t core to their business. Guidant itself was a spin-off from Eli Lilly about a decade ago.

Being a diversified health care conglomerate is challenging because some product lines make so much more money than others. Dealing with Procrit, stents, diabetes test strips and Splenda (not to mention baby powder) under one corporate roof certainly requires different management skills than big pharma usually exhibits, and it lowers the overall margins in the boom times. But when times are tough, it’s clear though that J&J’s diversification strategy has its advantages, given that it’s the only pharma stock to have actually gone up this year–up 20% compared to Pfizer for example which is down 20%. From that perspective Guidant looks to be a good, if somewhat pricey, addition to the J&J steamroller.

HOSPITALS: Trying to put King/Drew in context

There’s a really interesting series in the LA Times about King/Drew Medical Center.  The first article is called Deadly errors and politics betray a hospital’s promise, and the second is called Underfunding is a myth, but the squandering is real. Things are not good at King/Drew and have not been good for some time (possible since its founding). However, there are some reasons why that’s the case. Furthermore, (in a mostly unspoken way) this is somewhat being reduced to an issue about race, with some pretty negative connotations being made. And there’s a lot more to it than that.

I’ll say a lot more about this later in an attempt to put both the health care and the politics in some context, but for now go read the articles. (Apologies to my Monday readers but I’ve been crunched on something else the last few days).

PHARMA: Cynical thought for the day

On December 8th medical students across the nation are going to protest overly intrusive marketing from drug reps. I can’t help wondering that, given the relative geekiness and terrible work hours of medical students/residents and the typical physical characteristics of detail babes reps, isn’t this a somewhat excessive piece of self-sacrifice?  Where else are they going to meet hot chicks/hunky guys?

assetto corsa mods