The Health Care Blog – Page 681 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

But There Are No Pit Crews

Nov 16, 2011• 26

By Evan Falchuk

Atul Gawande says that we’re used to doctors working like “cowboys” – rugged individualists who are responsible for making sure your care gets done right. We don’t need cowboys, he says. We need “pit crews” – teams of doctors working together toward a common goal, with each playing their own role.

It’s an appealing idea. Pit crew-like teams work, and work well, in trauma units across the country.

But there’s a problem: if you haven’t just been airlifted to a hospital after a horrible accident, you’re not going to be treated by a pit crew. You’re going to be on your own, shuffled from one 15-minute specialist visit to the next, likely with no one person in charge of your care.

Dr. Gawande knows this, and he picks a heck of an example of the problem:

“But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to ‘protocol’ the MRI.”

Why is that such a good example? Because it’s exactly what happened to my brother at one of the leading medical centers in the country. He had a person directing the work up of his back pain and all the rest, including deciding on the right treatment for the “unexpected cancer found growing in his spine.” It all worked well….except that he didn’t have cancer at all. In fact, had he been treated for cancer, he might not be with us today.

End Gaming the Supreme Court’s ACA Review

Nov 16, 2011• 5

By Timothy Jost

On November 14, 2011, the Supreme Court decided to review a decision of the Eleventh Circuit Court of Appeals striking down the minimum coverage requirement of the Affordable Care Act (ACA) as unconstitutional. The case will probably be argued before the Court in March and decided in the early summer.

Procedurally, the Court “granted certiorari.” This means that it agreed to review certain questions raised by the certiorari petitions presented by the various parties in the Florida case, including the plaintiffs who challenged the constitutionality of the Affordable Care Act — 26 states, the National Federation of Independent Business, and two private individuals — and the federal government, which defended the Act’s constitutionality. The Eleventh Circuit had ruled against the federal government on the question of whether the minimum coverage requirement of the ACA is constitutional, but had ruled against the plaintiffs on all other issues.

The Supreme Court did not rule on certiorari petitions pending before it from the Virginia, Liberty University, and Thomas More cases, two of which rejected a challenge to the ACA on jurisdictional grounds and the other of which held the minimum coverage requirement to be constitutional. (The Virginia petition was not yet before the Court, as it was filed later than the others). The fact that the Court only granted petitions in the Florida case probably signals nothing about the Court’s ultimate decision, as the Florida case raises all of the issues raised by the other cases and reviewing additional cases would have merely made the case more complex administratively.

Denmark’s Fat Tax

Nov 16, 2011• 4

By Marion Nestle

The Danish government’s now infamous “fat tax” has caused an international uproar, applauded by public health advocates on the one hand and dismissed on the other as nanny-state social engineering gone berserk.

I see it as one country’s attempt to stave off rising obesity rates, and its associated medical conditions, when other options seem less feasible. But the policies appear confusing. Why Denmark of all places? Why particular foods? Will such taxes really change eating behavior? And aren’t there better ways to halt or reverse rising rates of diet-related chronic disease?

Before getting to these questions, let’s look at what Denmark has done. In 2009, its government announced a major tax overhaul aimed at cushioning the shock of the global economic crisis, promoting renewable energy, protecting the environment, discouraging climate change, and improving health – all while maintaining revenues, of course.

The tax reforms make it more expensive to produce products likely to harm the environment and to consume products potentially harmful to health, specifically tobacco, ice cream, chocolate, candy, sugar-sweetened soft drinks, and foods containing saturated fats.

Some of these taxes took effect last July. The current fuss is over the introduction this month of a tax on foods containing at least 2.3 per cent saturated fat, a category that includes margarine, salad and cooking oils, animal fats, and dairy products, but not – thanks to effective lobbying from the dairy industry – fluid milk.

You are Solving the Wrong Problem

Nov 14, 2011• 12

By Aza Raskin

There is some problem you are trying to solve.

In your life, at work, in a design. You are probably solving the wrong problem.

Paul MacCready, considered to be one of the best mechanical engineers of the 20th century, said it best: “The problem is we don’t understand the problem.”

Story time.

It’s 1959, a time of change. Disney releases their seminal film Sleeping Beauty, Fidel Castro becomes the premier of Cuba, and Eisenhower makes Hawaii an official state. That year, a British industry magnate by the name of Henry Kremer has a vision that leaves a haunting question: Can an airplane fly powered only by the pilot’s body power? Like Da Vinci, Kremer believed it was possible and decided to push his dream into reality. He offered the staggering sum of £50,000 for the first person to build a plane that could fly a figure eight around two markers one half-mile apart. Further, he offered £100,000 for the first person to fly across the channel. In modern US dollars, that’s the equivalent of $1.3 million and $2.5 million. It was the X-Prize of its day.

A decade went by. Dozens of teams tried and failed to build an airplane that could meet the requirements. It looked impossible. Another decade threatened to go by before our hero, MacCready, decided to get involved. He looked at the problem, how the existing solutions failed, and how people iterated their airplanes. He came to the startling realization that people were solving the wrong problem. “The problem is,” he said, “that we don’t understand the problem.”

THCB Live

Nov 14, 2011

Earlier this month, Chicago Mayor Rahm Emanuel talked about the innovative ways his administration is using health IT to fight rising healthcare costs. In his address, Emanuel announced that Merge Healthcare will donate 100 health kiosks to the city of Chicago. The kiosks are internet-connected health stations where consumers can check their vitals, including weight, BMI, blood pressure and heart rate for free.

Wal-Mart Care

Nov 14, 2011• 24

By John Goodman

Can Wal-Mart provide us with health care as efficiently as it furnishes us with paper towels?

According to a Kaiser Health News report:

Wal-Mart — the nation’s largest retailer and biggest private employer — now wants to dominate a growing part of the health care market, offering a range of medical services from basic prevention to management of chronic conditions like diabetes and heart disease, according to a document obtained by NPR and Kaiser Health News.

But then the next day, according to Kaiser, the company started backtracking:

The only thing the company would say for certain is: “we are not building a national, integrated, low-cost primary care health care platform,” according to the statement from to John Agwunobi, senior vice president and president of Wal-Mart U.S. Health & Wellness.

I’ll get to what Wal-Mart might be thinking in a minute. First questions first: Can Wal-Mart provide care that is of higher quality and lower cost than conventional provision? If so, how?

My answer: Wal-Mart can indeed improve on the current system. But here’s the catch. It can do so only if it continues doing what it and other retail medical outlets are already doing: ignore the third-party payers. Almost everything that’s wrong with our health care system is the direct result of third-party payment; and some of the most striking examples of efficient care are emerging in those parts of the market where third-party payment is either nonexistent or of marginal importance.

So as not to be misunderstood, I am not saying that our problems are being created by health insurance. There is nothing in principle wrong with insurance. The source of our problems is using insurance companies to pay medical bills. It’s insurance companies acting pro emptore — in place of the buyer.

Understanding the Supreme Court’s Health Law Review

Nov 14, 2011• 2

By Stuart Taylor, Jr.

By agreeing today to hear challenges to President Obama’s 2010 health care law, the Supreme Court set the stage for a decision — probably in late June and in the midst of the presidential campaign — that could be among its most important in decades.

The case, which will probably be argued in March on a date still to be announced, is especially momentous because it not only will determine the fate of President Barack Obama’s biggest legislative achievement but also will cast important light on the Supreme Court’s future course under Chief Justice John Roberts on issues of federal government power.

The central issue — but not the only important one — is whether Congress exceeded its constitutional powers to regulate interstate commerce and to levy taxes when it adopted the so-called “individual mandate” at the heart of the health care law.

That provision would require millions of people starting in 2014 to buy commercial health insurance policies or pay financial penalties for failing to do so.

The court also agreed to decide a challenge to the Affordable Care Act’s provision essentially requiring states greatly to expand their Medicaid spending.

The court made clear that if it decides to strike down the individual mandate or Medicaid provision, it will also decide which of the 975-page law’s hundreds of other provisions should go down too, by divining whether Congress would have wanted some or all of them to be effective even without the voided provision or provisions.

SCOTUS: Big News Is the Medicaid Grant

Nov 14, 2011

By BRADLEY JOONDEPH

So here are the two biggest consequences of the order:

* The Court has limited itself to the Florida case, and is presumably holding theThomas More Law Center and Liberty University petitions. (It will likely need to appoint someone to argue the AIA question against the parties.)

* The Court granted on the Medicaid question. This is a bit of a surprise, raising the constitutional stakes of the case rather substantially. For if the Court were cut back on Congress’s spending power, it would have significant long-term ramifications for the scope of federal power.

Again, the really big news of the morning — if there is anything surprising — is that the Court has decided to take up the constitutionality of the ACA’s Medicaid amendments. Specifically, the question is whether the spending conditions that the ACA imposes on the states are effectively “coercive,” such that they amount to an impermissible commandeering. There is no split on the question, and no lower court judge has yet voted to uphold the states’ claim. But the Court will take it up.

As a purely legal matter, this is a bigger issue than the individual mandate. For much of the modern liberal state is undwerwritten by Congress’s use of the conditional spending power.Continue reading…

Rethinking Medical Education

Nov 11, 2011• 25

By Victor R. Fuchs

Last spring, in his elegant commencement address to the Harvard Medical School, Dr. Atul Gawande appealed for a dramatic change in the organization and delivery of medical care. His reason, “medicine’s complexity has exceeded our individual capabilities as doctors.” He accepts the necessity of specialization, but he criticizes a system of care that emphasizes the independence of each specialist. Dr. Gawande is not alone in thinking that scientific, technologic, and economic changes require reorganization of care. Larry Casalino and Steve Shortell have proposed Accountable Care Organizations (ACOs); Fisher, Skinner, Wennberg and colleagues at the Dartmouth Medical School have focused on reforming Medicare, and many others have also called for major changes.

I expressed similar concerns in 1974 in my book Who Shall Live?, but at that time I rejected the claim that the problems of medical care had reached crisis proportion. In 2011, however, I agree with those who say the need for comprehensive reform must be marked URGENT. The high and rapidly rising cost of health care threaten the financial credibility of the federal and state governments. The former finances much of its share of health care by borrowing from abroad; the states fund health care by cutting support of education, maintenance of infrastructure, and other essential functions. These are stop-gap measures; neither borrowing from abroad nor cutting essential functions are long-run solutions. The private sector is equally distressed. Surging health insurance premiums have captured most of the productivity gains of the past thirty years, leaving most workers with stagnant wages. Not only is there a pressing need for changes in organization and delivery, but Ezekiel Emanuel and I, in our proposal for universal vouchers funded by a dedicated value-added tax, argue that such changes must be accompanied by comprehensive reform of the financing of medical care (Brookings paper).

But that’s not what I want to talk to you about today. My subject is the urgent need to change the structure of medical education. It seems to me that such change is necessary, and perhaps inevitable, given the revolution in medicine over the past half century, and given the changes in organization and delivery of care that lie on the horizon.

America Needs Different Doctors. Not More Doctors.

Nov 11, 2011• 43

By Merrill Goozner

Matt Yglesias at Think Progress took a look at some OECD data comparing U.S. physicians to their international counterparts and concluded we need more doctors. The evidence? There’s only 2.4 practicing physicians per 1,000 population in the U.S., second lowest in the OECD and somewhat below the 3.0 median (the range is from 2.2 physicians per 1,000 population in Japan to 4.0 in Norway). At the same time, the average U.S. medical consumer sees a physician only 3.9 times a year compared to the 6.3 OECD median. Yes, we pay a lot for health services including physician services (he reprints a chart showing average pay for U.S. physicians, whether highly paid orthopedic surgeons or relatively poorly paid primary care docs, that shows they are the highest paid among six well-off OECD countries). But his conclusion that America therefore needs more docs is off the mark.

This is a classic case where picking out a few trees as signposts in a dense forest of data leads one down the wrong path. His own charts show that the relatively small population of Japanese physicians enables that country’s general population to see a physician a stunning 13.2 times a year, twice the OECD average. One gets an image of a team of six doctors greeting every patient who walks in the door. Actually, that isn’t far from wrong. During my most recent visit to Japan, I visited a community clinic in Kumamoto Prefecture on Kyushu that gives local citizens their annual wellness exam, which is reimbursed under their national health care system. Every person is given a day off work to get this exam. At the clinic, the patients moved from room to room. At each stop over the course of a day, they were examined by different physicians and technicians who specialized in various aspects of personal health. A small number of doctors. A high level of primary preventive care with many hands-on encounters. Few visits to high-priced surgeons. Low overall health care costs.