Massachusetts Health Reform: The Canary in the Gold Mine?

Advocates for health care reform have been keeping an eye on Massachusetts, hopeful that its new health reform law will serve as a pilot program for the nation.

I’m much less hopeful than I was two days ago.

Yesterday I attended the Massachusetts Medical Society’s Eighth Annual Leadership Forum where I was one of four speakers. This year, the Society (which owns The New England Journal of Medicine)  focused on the cost of health care –with a special emphasis on funding universal coverage in Massachusetts. The new was not good. While the citizens of   Massachusetts believe that everyone has a right to health care (when polled 92% say “yes”), no one wants to pay for universal coverage.   When asked “if the only way to make sure that everyone can get the health care services they need is to have a substantial increase in taxes [should we do it] 55% said “no.”

One speaker at the forum recalled a man who explained why taxpayers shouldn’t have to pick up the bill: “The government should pay for it.” (He didn’t disclose who he thinks “the government” is. )

The FDA's Moment of Truth by Niko Karvounis

Soon we’ll see what the FDA is made of.

Yesterday the AP reported that “doctors told the Food and Drug Administration advisers that the over-the-counter [cough and cold] medicines shouldn't be given to children younger than 6 because they don't help them and aren't safe.” The final recommendation of an advisory panel of outside experts tasked with determining whether or not this is the case is due to the FDA late today.

By “not safe” petitioners don’t necessarily mean that the medicines themselves cause harm, but that they encourage reliance on “quick fixes,” an approach that can mask symptoms of more serious ailments.

This is obviously a problem in and of itself, but becomes an even a bigger deal when one considers that there are no known benefits to the medication. The drugs have never been tested on children—something the FDA has known since 1972. Instead, drug makers “have used extrapolated data from studies in adults to come up with dosing recommendations based on a child's age or size.” Hardly rigorous medical science.

The threshold for unacceptable risk is a lot lower when a medicine does nothing. Michael Shannon from the Children's Hospital Boston pediatrician and Harvard Medical School puts it best: “when a treatment is ineffective, its risks -- if not zero -- always will exceed its benefits.”

So what should worried parents do when their kids have a cold?

The Real Danger of Socialized Medicine by Niko Karvounis

Last week The Washington Post ran a good opinion piece by Ezekiel J. Emanuel, Director of the Clinical Bioethics Department at NIH (and brother of Congressman Rahm Emanuel) on the insidiousness of labeling any and all positions on health care apart from free market fundamentalism as being “socialized” medicine, doomed to failure.

Emanuel notes that “ ‘socialized medicine’ is when the doctors are state employees; when the hospitals, drugstores, home health agencies and other facilities are owned and controlled by the government…” As Emanuel rightly points out, none of the universal coverage proposals being debated in the U.S. today “can be characterized as socialized medicine. None calls for government ownership or control over U.S. hospitals, drugstores or home health agencies, or for making doctors employees of the federal or state governments.”

This is right on the money—maybe even more so than Emanuel intends. Opponents of “socialized” medicine are wrong three times over: not only do most reformers not want socialized medicine, but even European health care systems (often used as examples of socialized medicine) do not meet the criteria outlined above. Further, publicly-run health care carries with it some significant benefits that are evident right here in the U.S.

To dispel the myth of monolithic government-run European health care, look no further than Germany, where most of the population (88%) receives health care through “sickness funds"--non-profit, third-party pools of money devoted to health services. Sickness funds are built on the principle of “subsidized self-governance”: they receive public funding, but the funds must be financially self-sufficient (i.e. be able to govern themselves) and also allow a high degree of freedom on the part of patients and doctors (the former can choose their doctors and hospitals, and the latter have much flexibility in treatments).

Race and Health Care: Dimensions of Inequity by Niko Karvounis

Yesterday I talked a little about segregation of patients by race in NYC hospitals, and noted how this is likely a problem repeated across the nation. Wonder no more: a 2006 study in the Journal of the American Medical Association (JAMA) analyzed about 719,000 Californians who had received a wide range of complex surgeries. The authors found that blacks, Latinos, and Asians were far less likely to get these operations done at high-volume hospitals, which tend to have better outcomes for complex surgeries. (After all, practice makes perfect).

If you’re white, you’re more likely to receive care at high-volume, better-performing hospitals. This is bad in and of itself; but unfortunately, discrimination continues beyond the level of medical institutions and into the level of individual doctors. A 2004 study in the New England Journal of Medicine looked at the primary care experience of Medicare patients, specifically looking at 150, 391 visits by black and white Medicare beneficiaries for “medical evaluation and management who were seen by 4355 primary care physicians.” Here is what they found:

“Most black patients were confined to a small group of physicians (80 percent of visits were accounted for by 22 percent of physicians) who provided only a small percentage of care to white patients. In a comparison of visits by white patients and black patients, we found that the physicians whom the black patients visited were less likely to be board certified (77.4 percent) than were the physicians visited by the white patients (86.1 percent) and also more likely to report that they were unable to provide high-quality care to all their patients (27.8 percent vs.19.3 percent).

Why We Don‘t Have Enough Nurses (It's Not Low Wages)

Consider this: In the San Francisco area, a nurse with a bachelor’s degree can hope to start out with a salary of $104,000. The salary for a nursing professor with a Ph.D. at University of California San Francisco starts at about $60,000.

This goes a long way toward explaining why nursing schools turned away 42,000 qualified applications in 2006-2007—even as U.S. hospitals scramble to find nurses. We don’t have enough teachers in nursing schools and the fact that the average nursing professor is nearly 59 while the average assistant professor is about 52 suggests that, as they retire, the shortage could turn into a crisis. The most recent issue of JAMA (October 10, 1007) reports that in 2005 we had 218,800 fewer nurses than we needed and by 2020, it’s estimated that we’ll be short some 1 million nurses.

Hospitals have had to raise nursing salaries (as well they should), not just because nurses are scarce but because, in our chaotic hospital system, the work can be extraordinarily stressful.   

Race and Health Coverage: Medical Apartheid?

I've invited Niko Karvounis, a colleague at The Century Foundation, to guest-blog. Niko is currently a Program Assistant at the Foundation and an Alumnus Senior Fellow with the Roosevelt Institution. His post follows below.

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Recently I was handed a report from Bronx Health Reach (BHR) entitled “Separate and Unequal: Medical Apartheid in New York City” that reveals some startling inequities right here in the so-called capital of the world.

Bronx Health Reach is a coalition formed by the Institute for Urban Family Health, with the mission of examining and addressing racial and ethnic health disparities in the southwest Bronx portion of NYC.

At the local level in the Big Apple, these disparities play out through discriminatory care tied to health coverage. Since “health insurance is a major determinant of access to medical care,” poor insurance increases the probability of “delayed care and poorer health outcomes.” And in NYC, health insurance status is closely linked to race: “52 percent of blacks, 63 percent of Latinos” and only “24 percent of whites are uninsured or publicly insured.”  This skewed distribution of health coverage ultimately “creates a de facto sorting of patients by race.”

The most compelling evidence of apartheid can be found in the records of medical institutions which reveal the characteristics of patients that they admit and discharge.

Do You Want to Know That You Will Be an Alzheimer Patient in Two to Six years?

Yesterday The New York Times reported a medical breakthrough: “the development of a blood test that can  accurately  diagnose Alzheimer’s disease, and even do so years before truly debilitating memory loss.”

Well, “accurately” may be a bit of a stretch. As the Times explained, the test is about “90 percent accurate in distinguishing the blood of people with Alzheimer’s from the blood of those without the disease” and “about 80 percent accurate in predicting which patients with mild memory loss would go on to develop Alzheimer’s disease two to six years later.”

Then, the Times acknowledged, there is one other problem with the test:  “At present, treatments for Alzheimer’s disease are not very effective.”

So why exactly would I want an early warning that would give me two to six years to contemplate what it will be like to observe my mind dissolving? (Of course I could comfort myself with the fact that the test is only 80 percent accurate, but somehow I suspect that would only compound my anxieties.)

“There are people who want to know what their future holds so they can plan their estates and lives,” Dr. Sam Gandy, a professor at Mount Sinai School of Medicine in New York who is chairman of the medical and scientific advisory council of the Alzheimer’s Association, told the Times.

Right, this is an estate planning tool.

When Women and African-Americans Receive Better Care Than White Men

Last week a new study in the Journal of the American Medical Association documented yet another case of discrimination in American medicine. It turns out that blacks and women suffering from heart disease are much less likely than white men suffering from a comparable level of disease to have a defibrillator (a cutting-edge device that uses a jolt of electricity to shock an erratically beating heart back to a normal rhythm) implanted in their hearts.

But as Merrill Goozner points out at GoozNews:  "Guess what? They may be the lucky ones, at least when it comes to implantable cardioverter-defibrillators (ICDS) . . ."

The study showed no benefit for the white men who received the implant. Below, Merrill's analysis, plus his comment (from a separate post) on the need for more and better research into the effectiveness of new drugs and devices:

More Thoughts On the Hospital Building Boom

A Startling Insider’s Look at What Happens to Patients Who Stay in the Luxury Suites of a Prestigious Hospital                         

Last week, thehealthcareblog.com (THCB) asked if they could put up my post about the hospital building boom below where I ask “Can we Afford the Waterfalls”-- and all of  the other hotel-like amenities that new hospitals are beginning to offer. Do we really need grand pianos, valet parking and all-private rooms—especially in hospitals that don’t yet have electronic medical records? (See my original post here)          

Quite a few readers at THCB commented, with a number voting “yes” for the amenities.  But one young doctor said “no”—and then offered this startling insider’s  view of  the care patients do and don’t receive on the luxury floor of one prestigious hospital:

“Maggie's right-on regarding the disconnect between hospital frills and quality of care...

How Not-For Profit Hospitals Hooked on Growth Can Help Bankrupt the System

In response to the questions I raised in two posts below about the hospital building boom and whether we need—or can afford—hotel-like amenities, Dr. Terry Bennett sent HealthBeat the story below. It’s a provocative insider’s look at how a local hospital is raising the money for an “expansion” that, according to Bennett, seems to have very little to do with improving the health of its patients or the local community. Part problem is that CEO’s of non-profit hospitals have begun to think like CEO’s of for-profit corporations: growth is always good.

“If you own all of the doctors’ practices that refer to a community hospital—as the CEO of our local hospital does-- you can dictate where, when and for how much every single patient is seen,” Bennett writes.” For example, you can make sure that all urgent cases are seen in your hospital’s ER at $1000 a head. (Medicare and Medicaid pay less than a grand for a "bare bones" ER visit, but if you order an EKG, an x-ray or two, and a few lab tests, you can push the visit up to over $1000).

“Do that 100 times a day and you have millions [of dollars] which you need to cause to vanish as quickly as possible. [Otherwise the Centers for Medicare and Medicaid services may question how a not-for-profit could be making such rich profits, and start to examine your books.] Thus the Atria, the waterfalls,the new facades, the many other flashy dashy add-ons, the services no body really needed.

“The CEO of our local hospital hates me. Because my patients can reach me 24/7, I have the lowest ER admission rate of any physician on the staff at my local hospital. I treat over the phone, see the next day, am always on the prevention line of chatter, etc. [In other words Dr. Bennett is not helping the CEO fill the hospital’s coffers].

“Meanwhile, our hospital, is in the midst of a $45 Million ‘expansion’--- no new beds, no new services, but $45 million is being buried, and ‘non profit status’ is preserved. It is happening in almost every community across the USA. Such antics make any healthcare budget, Medicare, Medicaid, or HMO, completely unpredictable and are bankrupting the entire present system and all of its budgeting assumptions—and will continue to do so until forcibly stopped.”

Dr. Bennett also included a copy of an Op-ed which originally appeared in two New Hampshire newspapers, the Portsmouth Herald and the Rochester Times. Below, an edited version:

Health care issues in the new millennium
By Dr. Terry M. Bennett

It seems like only yesterday, but it was in fact 16 years ago, 1992, when I ran for a New Hampshire Senate seat proposing a single-payer Medicaid-based national health care plan using our Social Security numbers for identification.