THCB

Categories

Above the Fold

QUALITY/PHYSICIANS: I disappoint the Industry Veteran, with UPDATE

My corrrespondent the Industry Veteran was upset to see me teetering on the doctors’ side, while trying vainly to take the middle road, in the malpractice debate that I highlighted here last week. Meanwhile the same issue (the web site that identifies plaintiffs for doctors) has been busying a slew of doctors and a few of their detractors over at MedRants. The Veteran writes to point out the error of my ways!:

    I was sorry to see your statement that you "take the doctors’ side" in their battle against the malpractice lawyers. Among those who deserve blame for the shortcomings and inequities in this country’s two-tier healthcare system, organized medicine is at least as blameworthy as hospitals, Big Pharma and insurance companies. Although you back away from this ill-considered partisanship in subsequent sentences, your initial sentiment reveals a reflexive simpatico that you should try to eradicate.In the first place, efforts to assign principal blame for the healthcare system’s problems remind me of the old Chicago scholasticism that sought to place responsibility for the city’s corruption on either the politicians, the police, the gangsters or big business. All the participants have historically sought to dip their beaks in the public’s blood and, in the case of healthcare, the providers have enacted the Tony Soprano role to an extent equalling that of manufacturers and payers. Paul Starr’s Social Transformation of American Medicine and other monographs have described the tactics that organized medicine used to elevate medical practice from a middling, lower-middle class occupation at the start of the 20th century (when the requirement for admission to Harvard’s medical school consisted of the ability to read and write) into the significant holder of gross domestic product that it is today. "In the physicians’ view," according to Starr, "the competitive market represented a threat not only to their incomes, but also to their status and autonomy…and threatened to turn them into mere employees."While increasing a profession’s exposure to tort liability is rarely the sole means of reforming public policy, I believe that in this case malpractice actions do help to advance the process. Dragging physicians into the dock furthers the demystification and dissipates the profession’s unchallenged self-judgment, both of which permit physicians to insert economic bottlenecks into healthcare while making the provider sector a two-caste system. Other positive functions of malpractice activity include making medicine less attractive to the spoiled princes (and, increasingly, princesses) of American society. Certainly I agree with your contention that the necessary process of knocking physicians from their pedestal can be abetted by the increased use of physician extenders (I prefer the term used by labor historians: "de-skilling") and the enforcement of evidence-based logarithms to constrain self-indulgent, self-dealing, cost escalating "autonomy." Despite the nervous handwringing from some of your fellow bloggers, I also want to advance the feminization (more accurately, the "mom-ification") of medicine to deter avaricious ambition from the profession (keep the Jeff Skillings and the Billy Tauzins in business and policitics where they belong) while making it more hospitable to the needs of 9-5, live-and-let-live employees.I think we can proceed through a long, tedious dialogue on this issue, and we’d probably conclude with more agreement than disagreement. I don’t wish to engage in such a colloquoy, and would instead urge a way for you to expunge your reflexive sympathy for physicians. Instead of maintaining the preconscious image of a workaday British physician such as your father, think instead of the two-dollar whores who demand that the pharmaceutical companies entice them to breach fiduciary responsibilities to patients.

UPDATE: (late Weds) The Veteran‘s anti-physician line may be a little extreme for me, but nothing to the extent to which it’s upset the medblogshpere’s favorite surgeon. Go see Bard Parker‘s reply at A Chance to Cut…

HEALTH PLANS: Look who’s getting into the business

You know that health plan margins are too high when you see who the latest entrant into the business is. Yup, Walmart, the 800lb gorilla of brutal discounting is now offering health insurance for small businesses via it’s Sam’s Club. Those providers who’ve been complaining about harsh discounting from aggressive managed care firms haven’t seen anything yet! I can just see America’s hospital and physician and pharma execs waiting for their turn in the "seven-by-ten-foot blue roomlet–one fluorescent light, one table, one photo of Mr. Sam. So, says the buyer in his unfailingly polite manner, how can your company help Wal-Mart?"

test post

This is a test of the emergency formating system.

POLICY: Enthoven’s lament, with UPDATE

The new Health Affairs is out and it’s fascinating. This journal is over 20 years old and getting better and better. I’ll try to run something from it every day this week. Sadly if you want the full articles you have to subscribe, at about $100. It’s well worth it (and I do) but I think that it’s so valuable that I wish RWJ or someone would just fund it in perpetuity so that it’s all freely available.

The first article that jumps out at me is a commentary from Alain Enthoven about not why competition has failed but why (in his words from a decade or so ago) “it hasn’t been tried.” I learnt much of what I know (and believe) about health care from Enthoven in his classes at Stanford and he in those days delivered a biting expose of the failure of government regulation to create the conditions for sensible competition in the healthcare system, which remains true to this day. His “managed competition” model was at least the partial basis for the Clinton plan, although he fell out with the Hillary team fairly early on in the process.

I somewhat parted the ways with his philosophy when he put (at the time of the Clinton plan) the interests of the market over the interested of universal insurance — as it turned out neither happened legislatively. But what is very interesting is that Enthoven has also been watching the slow emergence of what Bob Leitman calls the problem of the Nascar dads, and the rest of the baby boomers heading to, but not quite getting to Medicare by 2008-16. Here’s his forecast, and lament:

    Why not “Medicare for All”?

    It is late, probably too late, to avert the inexorable progression to “Medicare for All.” U.S. employers would need to have an epiphany soon. But when it comes to health care, most of their horizons are so limited and their vision so constrained that such a change seems unlikely.

    What is becoming most likely is that the winning candidate in 2008 will make “Medicare for All” a foundation of his or her platform. And employers, incapable of controlling costs and desperate to get medical expenses off their financial statements, will lead the candidate’s campaign finance committee. Labor and small business will join them. The large and growing numbers of uninsured, by then reaching well into the middle class, will consider the issue to be of top priority.

    While I would welcome universal coverage as long overdue, I think it would be a tragedy to lock in FFS Medicare and deny people the opportunity to save money by choosing less costly options. The recent Medicare “reform” debate shows that it will be almost impossible to dislodge FFS from Medicare. FFS makes doctors and payers adversaries. It punishes doctors for innovating in ways that make their costly services less needed. The burden of chronic disease is growing rapidly, yet our FFS delivery system is oriented toward episodic, acute care. FFS promotes the wide variations in practice patterns documented by John Wennberg and colleagues. And it certainly does not motivate quality improvement in the sense of discouraging overuse, underuse, and misuse. Providers do not bear the costs of their poor quality.“

I think his forecast is right and that his fears of a locked -in over politicized fee-for-service Medicare-for-all at some point out beyond 2010 is the likely scenario. The alternate is the Brazilianization of the US social welfare system into one for the very rich and chaos for everyone else. However, I’m not as pessimistic as Alain about the end result of that first option.

First, whatever its faults Medicare-for-all would be better for a significant chunk of the population than what we have now–including the uninsured, the underinsured and those under 65 who really need help but can’t get it, as well as those over 65 who need better drug coverage than they have now (and still won’t have after PDIMA). It would not be that much worse for anyone (other than vastly over-paid specialists, who would still get by OK).

Second, Americans love medical technology and even under a state run system they’ll happily tax themselves to get it, so we are not heading to Canada or the Soviet Union (and you won’t catch me lumping those two together that often!)

Third, I’ve concluded that meaningful reform is only possible under a single-payer system. The things we need like universal pooling of risk, and public funding for a common data exchange system can only come about easily under a single-payer/government system. It may take us a long time to get there after Medicare-for-all, but for an example look at the Brits who, much influenced over the years by Enthoven, are making the right moves to get a single-payer system in place that rewards the pay-for-performance (or at least pay-for-process) that Enthoven favors, and are putting the information technology in place that will deliver the consumer friendly health-care Jeff Goldsmith wants. (More on that later!)

UPDATE: Don Johnson (a non-foaming-at-the-mouth Republican, and yes there are some!) has some criticism of both my and Enthoven’s approach over at the Business Word. Read his point and my reply at his post.

TECHNOLOGY: Stents now movin on up, with UPDATE

Loads from the American College of Cardiology meeting including a detailed study on stent use in the carotid arteries from Guidant (here’s the more digestible press release) and also "proof" from J&J that drug eluting stents really, really prevent restenosis — honest!!

Meanwhile over at MedRants more on the latest with the statins. (Short version is that stronger is better so Lipitor beats Pravachol but may get bested by Crestor).

Funnily enough the meeting is in New Orleans, so from my recollection of the food down there, plenty of future work for these statins and the stent manufacturers is being created each dinner time!

UPDATE: Sydney Smith over at Medpundit has a very interesting take on the real world application of this study and isn’t so sanguine about it.

PHARMA: HHS’ Thompson reads THCB

OK, maybe not, but in talking to a congressional committee who’s members do, or at least do read opinion polls like these, HHS secretary Thompson hints that the Republicans might cave on the drug re-importation issue to save the most unpopular part of the Medicare bill from becoming an election issue. Perhaps they noticed that Florida and Pennsylvania are both full of seniors and are both needed to be in the Red column on Nov 2, if Dubya is going to stay in the White House.

INDUSTRY: Scrushy goes on TV with Roy Moore to proclaim innocence

It’s so hard to resist, and I’ve been good for so long, but I had to re-open the Healthsouth file. The story so far. 15 execs admit years and years of fraud. CEO Richard Scrushy claims he knew nothing about any of it, despite the fact that plenty of his staff say he led the whole thing. Now Scrushy has his own TV chat show and his first guest was whacko Alabama chief justice Roy Moore–the one who put the Ten Commandments monument in his courthouse. Anyway, they are both agree that the media has cooked this whole thing up and Scrushy, like Ken Lay, was merely an innocent bystander while his underlings plundered and cheated the company. And if you don’t believe him, because, well, because you’re just not a trusting person, he’s got his own website to prove it!

It reminds me a little of the Chaing-Kai Shek War Memorial in Taiwan, which has a long exhibition showing how the Nationalists really won the 1949 Civil War with their strategic retreat from Beijing to Taiwan! Of course usually losers don’t get to write the history books, so it’s nice to see Scrushy joining in a rare tradition. Methinks that if Martha goes down, he’s bound to follow–but of course I won’t be on a jury in Alabama!

QUALITY/PHYSICIANS: When war is declared it’s hard to find a middle way

In Friday’s NY Times there’s an article called In Texas, Hire a Lawyer, Forget About a Doctor?. The article features a database online called DoctorsKnow which allows doctors (for a fee of course!) to find out which of their patients has sued any doctor. The logical conclusion to this is that anyone who has ever sued a doctor cannot get any care. As this behavior starts up for real rather than just as a philosophical debate in Medrants, it strikes me that we are getting to the point at which war is starting. Many doctors might say that the trial lawyers have already been at war with them and they’re just responding. Most of you know that I’m on the physicians’ side in this battle, but believe that averting the war is a much more desirable outcome than fighting it (which reminds me of the Iraq situation!).

Matt Quinn, who some of you may suspect is on the lawyers’ side captures my feelings in this note:

    This article speaks to the need for someone to be a moderating force in this debate: of course, all trial lawyers aren’t bad, all doctors aren’t bad, and all people who sue for malpractice aren’t bad. Perhaps the government (CMS?, AHRQ?, ???) could convene the AMA, ATLA and other entities to come together to propose a centrist solution that provides justice for all. That would require both of those organizations to set aside some of the immediate narrow self-interests of their memberships and work together for a sustainable solution that solves the problem – something that would benefit all stakeholders involved, including (last but not least) the thousands of people who are harmed each year by malpractice. Not likely in an election year.

Unfortunately Matt’s right. While this fight get politicized it cannot be changed into a sensible peace settlement. Unless of course organized medicine breaks away from the mainstream "tort-reform" movement that’s really a part of corporate America wanting to pursue unmitigated bad behavior, and proposes a different tack in cooperation with moderate voices for sanity in medicine like the IOM.

TECHNOLOGY: Drug-eluting stents take off–With late afternoon UPDATE

As this study from Solucient shows the take off in the use of drug-eluting stents has been very fast, even before Boston Scientific’s Taxus stent hits the market. USA today has a good general article about them too.

This puts hospitals in a real bind, as the cost of the new stents means that they’ll be losing money on their use, unless they can get an increase in DRG payments from CMS. So watch this space. But don’t forget that restenosis rates are real even for drug-eluting stents and that a recent Stanford study showed you were better off getting a by-pass over time.

UPDATE: The FDA today as expected approved the Taxus stent from Boston Scientific. The stock is up about 30% so far this year.

assetto corsa mods