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Op Ed: Make It Simple, Please!

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By ALAN WEIL, JDAlan Weil Photo

The Patient Protection and Affordable Care Act creates a continuous set of coverage options for every American with income below 400 percent of the federal poverty level, or about half of the nation’s population. Sounds simple, right? To participating families it needs to be, but it will take a tremendous amount of work and creativity on the part of states and the federal government to achieve this vision.

The Affordable Care Act’s guarantee of coverage is actually a patchwork quilt that includes Medicaid, the Children’s Health Insurance Program, employer-sponsored coverage, and plans purchased with subsidies through the new insurance exchanges. While almost everyone will be eligible for some form of coverage, the source of coverage matters because it determines the benefit package, the cost-sharing provisions (deductibles and co-pays), and how costs are allocated between state and federal governments.

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Dr. Berwick’s Last Stand?

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By MAGGIE MAHAR

Kaiser Health News (KHN) reports that “the nomination of Dr. Donald Berwick to run the agency overseeing Medicare appears to be languishing.”   Friday, KHN’s “Health Policy Week in Review” quoted a story that appeared in the New York Times a few days earlier:

“Hospital executives who have worked with Dr. Berwick describe him as a visionary, inspiring leader. But a battle has erupted over his nomination, suggesting that Dr. Berwick faces a long uphill struggle to win Senate confirmation. Republicans are using the nomination to revive their arguments against the new health care law, which they see as a potent issue in this fall’s elections, and Dr. Berwick has given them plenty of ammunition. In two decades as a professor of health policy and as a prolific writer, he has spoken of the need to ration health care and cap spending and has confessed to a love affair with the British health care system.”

KHN also points out that according to The Hill, although Senate leaders are nearing an agreement to allow more than 60 Obama nominees to be approved to begin work, Berwick is not on the list  . “‘He will not get unanimous consent,’ a spokesman for Senate Minority Leader Mitch McConnell (R-Ky.) told The Hill.

I am not at all persuaded that Berwick’s confirmation is in trouble. As the highly-respected president and CEO of the Institute for Health Care Improvement, Dr. Berwick enjoys support that ranges from the AARP to three former directors of the Centers for Medicare and Medicaid (CMS) who served under Republican presidents. “This is not really about Don Berwick,” John Rother, executive vice president for policy and strategy at the AARP told McClatchy Newspapers. “In ordinary times, the nomination of somebody with Don’s record and standing in the field would not be controversial.” Thomas Scully, who led the CMS under President George W. Bush agrees: “He’s universally regarded and a thoughtful guy who is not partisan. I think it’s more about … the health care bill. You could nominate Gandhi to be head of CMS and that would be controversial right now.”Continue reading…

The Top 10 Generics

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By ED PULLEN, MD

Many of the breakthrough drugs of the 1980-1990′s are now available
as generics, and pharmacy competition has led to great bargains for
patients needing these drugs.

The 1980’s and 1990’s were a golden age in the development of great
new drugs to treat many common and uncommon diseases.  Prior to that
time it was very difficult to treat depression, hypertension,
diabetes, and congestive
heart failure. It was nearly impossible to treat high cholesterol.
Breakthrough drugs like the SSRI
antidepressants, ACE
inhibitors and calcium
channel blockers for hypertension, metformin
for diabetes, and several drugs in combination for congestive heart
failure came to market, and have revolutionized the care of many of
these chronic diseases. Now the great news it that many of these drugs
are available as generics, and competition between retail pharmacies has
led to incredibly cheap medication.  Here is my top ten list of great
generic medications.

  1. ACE inhibitors. I tend to use lisinopril, but
    several others are also available.  These meds are effective at
    controlling high blood pressure, but have also been shown to prevent
    heart attacks in patients post MI, to prolong life and reduce
    hospitalizations in congestive heart failure, to prevent diabetes
    related kidney failure, and is usually extremely well tolerated.  A
    small percent of patients get a cough, and even smaller percent are
    allergic to these medications.

  2. Statins This class of LDL cholesterol lowering drugs has made effective treatment of high cholesterol practical and simple. Several have gone generic including simvastatin, lovastatin, and pravastatin. Although simvastatin (Zocor) is not on the chain pharmacy $4. drug lists, it is quite inexpensive ($10.90/ 100 40mg doses at Costco) and is effective enough for most patients to achieve goal LDL cholesterol levels.  Many studies have shown statins to be effective at lowering rates of various cardiovascular diseases.

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Heavy Words

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By ROB LAMBERTS, MD

The post that forever doomed the world to have my writing forced onto them was one called Shame, in which I describe my frustration with how society stigmatizes people who are obese.  It was picked up by the NY TImes Health Blog and got a good conversation about the subject going on the blog-o-sphere.

A recent article in EverythingHealth (via Better Health) got me thinking again about the subject of society’s response to the “obesity epidemic.”  The article discusses a recent study that showed…well, read it for yourself:

Talk about a cruel trick of nature!  A study funded by the National Institutes of Health (NIH) and published in JAMA shows that physical activity prevents weight gain in middle-aged and older women ONLY IF THEY ARE ALREADY AT IDEAL WEIGHT. Did you read that?  It means that the recommended guidelines advocating 150 minutes of exercise a week isn’t sufficient to prevent weight gain in most middle age women.

The author, Dr. Toni Brayer, ends the post by saying:

So what are we to think about this study?  First, caloric restriction is the only way to maintain or lose weight.  The health benefits of exercise have been proven over and over in thousands of studies and that is not in dispute.  But weight control demands caloric restriction, period.

I am sorry about these results. Truly I am.

Hearing the frustration from my patients (male and female), and struggling with weight myself, I have to say that this is not really that surprising.  Losing weight is not easy.  Let me say that again: losing weight is not easy.  There are lots of reasons it is difficult to lose weight, from the food-oriented culture to a person’s own metabolism.  There are emotional and addictive aspects to obesity as well.  This study puts scientific evidence behind the hardness of weight loss.Continue reading…

Contradictions in Massachusetts

By PAUL LEVY
Paul Levy 1

I have written before
about the strange things going on in the Massachusetts health care
insurance market. For those from out of state, here are some quotes
that will give you a sense of the contradictions in the public policy
arena.

They are, respectively, from two stories that appeared on
the same day in the Boston Globe:
"Rate
cap for insurer overturned" and "Officials
give up cutting health perks."

(1) An insurance appeals board yesterday overturned the state’s
cap on health premium increases for small business and individual
customers covered by Harvard Pilgrim Health Care . . . [finding] that
rate increases Harvard Pilgrim initially sought in April are
reasonable given what it must pay to hospitals and doctors. That ruling
trumped the Insurance Division’s earlier finding that the requested
increases were excessive.

(2)
The state’s public employee unions won a major victory this week when
the Legislature abandoned efforts to allow cities and towns to trim
generous health care benefits enjoyed by thousands of municipal
employees, retirees, and elected officials.

You can read
the rest and related stories, but what is most disturbing is that the
spirit of cooperation and compromise that existed when Massachusetts
approved its health
care reform law in 2006 has broken down. Part of the reason is
that commitments made at that time have not been delivered upon. For
example, the state had promised to lift Medicaid payment rates to
something closer to the cost of delivering that service. Once the
economy sank and state budgets were stressed, that was not possible.
This left providers needing to collect more of their income from private
insurers.

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What’s New With McKesson HS

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By Matthew Holt

At the AHIP Conference I got a chance to sit down with McKesson Health Solution's Senior VP of Care Management Jim Hardy and VP of Product Development Kevin Maher. The two men were more than happy to share with me some new products that McKesson HS has developed. One product is the Personal Health Advisor that was introduced in the beginning of this year.

If HIT Plan A Doesn’t Work, What’s Plan B?

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By VINCE KURAITIS, JD, & DAVID KIBBE, MD

Pop quiz: Among early-stage companies that are successful, what percentage are successful with the initial business model with which they started (Plan A) vs. a secondary business model (Plan B)?

Harvard Business School Professor Clay Christensen studied this issue.  He found that among successful companies, only 7% succeeded with their initial business model, while 93% evolved into a different business model.

So let’s take this finding and reexamine our human nature. In light of these statistics, what makes more sense:

  • Defending Plan A to your dying breath?
  • Assuming Plan A is probably flawed, and anticipating the need for Plan B without getting defensive?

We question many of the assumptions underlying HITECH Plan A. We also want to talk about the need and content for Plan B in a constructive way.Continue reading…

Are Doctors Really Boycotting Medicare?

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By NAOMI FREUNDLICH

Naomi FreundlichAs Congress once again wrestles with “the doctor fix”—yet another postponement of the 21% cut in Medicare reimbursement that went into effect this month—the media has been swirling with stories warning of a mass exodus of doctors out of the federal program. The reason: In 2008 Medicare paid doctors 78% of what they get from private insurers; with the 21% cut they fear that their income will drop even lower.

The reports hit their peak late last week—USA Today wrote that “[t]he number of doctors refusing new Medicare patients because of low government payment rates is setting a new high,” while the American Medical Association announced that 31% of primary care doctors are restricting the number of Medicare patients they take. In a recent survey, the American Academy of Family Physicians found that 13% of respondents didn’t participate in Medicare last year, up from 8% in 2008 and 6% in 2004. Chic Older, executive director of the Arizona Medical Association told the Seattle Times ; “If the 21 percent cut goes into effect, we’re going to have a very severe problem in the state of Arizona.”

The question is: Will Medicare beneficiaries really face a shortage of providers and restrictions on their access to care? Or is this a scare tactic being used for political reasons?

First off, all this is happening against the backdrop of a major political fight in Congress over how much the government should invest in economic recovery. On Friday, the Senate passed a “doc fix” that would postpone the 21% cut in Medicare payments for another six months and provides a 2% increase in reimbursement instead. Unfortunately for doctors—and the seniors they count as patients—Nancy Pelosi has signaled that she may not be willing to settle for such a short-term solution. According to Politico, Pelosi was “caught off guard last week when Reid suddenly opted to pull the Medicare issue out of a jobs and economic relief bill on which the two leaders have been working for months.” For more background on the long history of the “sustainable growth rate” formula that mandates the Medicare cuts (enacted in 1997 by a Republican administration) and the unlikelihood of it ever being instituted long-term, see Maggie’s recent post here.Continue reading…

A Tale of Two Diseases: Repairing Comparative Effectiveness Research

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By DAVID E. WILLIAMS

Writing in the New England Journal of Medicine (Identifying and Eliminating the Roadblocks to Comparative-Effectiveness Research) three authors share their experience in running a head-to-head trial of Avastin (bevacizumab) versus Lucentis (ranibizumab) for wet age-related macular degeneration (AMD). They describe the barriers they faced and suggest that they will need to be removed for comparative effectiveness research –as envisioned under ARRA– to succeed. They make good points and may well be correct in their policy recommendations.

However the case of Avastin and Lucentis is unusual. The products are made by the same manufacturer and are essentially identical. Avastin and Lucentis are marketed separately by Genentech mainly to allow the company to capture a return on investment from its R&D. The issue is that a regular dose of Avastin (e.g., for lung cancer) can be divided up into many doses for the eye. Since the products are sold by volume it turns out that Avastin is cheap when used for wet AMD, even though it’s pricey when used for cancer. As I’ve suggested previously, Genentech should be able to charge Lucentis prices for Avastin when it’s used in the eye. So there are quite a lot of people –starting with the manufacturer itself– who didn’t really want this study to go forward. That’s less likely to be the case with other studies.Continue reading…

Why England is out of the World Cup

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By Matthew Holt

Matthew holt

I don’t often write about Footy any more on THCB, but England is out of the World Cup today, stuffed 4–1 by Germany. So I thought I’d give my opinion, and for the moment I’m dropping my dual nationality and writing as an Englishman!

Why did we lose? Realistically England doesn’t have enough good players because England’s population is too small (50m vs 80m Germans) and—as pointed out in Soccernomics—the working class ethos against middle & upper class kids limits our potential pool of players even more—as England’s working class population is falling relatively as more kids go to college. In general England could improve our football team by changing its economy to match the slums of Argentina’s or Brazil’s but I wouldn’t take that as a fair trade. After all, the US dominates international sport (except its fifth most important sport soccer) because it has a huge urban underclass with a great feeder system (that’s colleges!) to getting them into basketball/American Football/Track etc. And it may well be that with more and more kids from the big urban centers getting into soccer, America can only improve. It’s a decent prediction that the US will win the World Cup in the next 50 years or so. Unlikely that England ever will again.

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