Update No. 3 on the Checklist story

At Wachter’s World, Bob Wachter, Professor and Associate Chairman of the Department of Medicine at the University of California, San Francisco explains more about how the government’s attempt to stop the use of checklists in ICUs could undercut efforts to improve quality in hospitals nationwide.  He also gives you a chance to write to your Senator or Congressman. Go take a look.

WSJ Editorial on Liver Transplants Cherry-Picks the Numbers

Dr. Scott Gottlieb, a resident fellow at the conservative American Enterprise Institute, published an op-ed in the Wall Street Journal last week that returned to the much-exploited story of Nataline Sarkisyan, the 17-year-old Californian who died before receiving a liver transplant. Gottlieb used the story to make the argument that “the U.S. has the best health care in the world.”

Gottlieb is squaring off against John Edwards, who has been suggesting that if Nataline had lived in a European country she might have lived.  Edwards blames CIGNA, her for-profit insurer, for refusing to cover the procedure. Dr.  Gottlieb, who is a former FDA official, responds with a double-barreled argument: “Americans are more likely than Europeans to get an organ transplant, and more likely to survive it too.”  He sounds confident, and at first glance, his argument seems persuasive.

But a closer look reveals that Gottlieb makes his case by carefully culling the numbers that fit his argument, while omitting those that don’t. Unfortunately, too many people involved in the healthcare debate play fast and loose with the facts. Everyone interested in reform should be on the look-out for those who don’t cite solid evidence for their assertions. If they don’t give you their source, it may be because they don’t want you to look it up—and because they realize that they are cherry-picking the numbers.

Before engaging Gottlieb’s argument, I should acknowledge that, as I have said in an earlier post, I think Edwards has picked a bad case to make his argument for healthcare reform. I am not at all certain that the transplant would have helped this particular patient.  And while Edwards puts all of the blame on CIGNA, Nataline’s insurer, I am bothered by the fact that the hospital asked for a $75,000 down payment on the surgery and then refused to go forward without it. As one physician/blogger from the very same hospital where Nataline was treated asked: “Why didn’t the hospital simply perform the surgery and defer payment from the family or CIGNA [Nataline’s insurer] until later? If it was such a great idea, why didn't they exhibit the outrage and strength of conviction to go ahead regardless of CIGNA's assessment?” 

That said, I agree with Edwards and other proponents of health care reform that, in other countries, decisions about whether or not to pay for expensive procedures like transplants are not based on whether the patient has the money or the insurance to pay for the operation. Instead, in other developed countries, such decisions turn on whether the benefits of the treatment outweigh the risks—and whether the procedure is cost-effective.

Glenn Beck Gives Birth to a New Health Care Myth

Over on CNN.com, I came across one of the most wrong-headed arguments against health care reform that I’ve ever seen in my life. Here’s the gist of it: we can't reform the health care system until doctors are nicer to their patients. Perhaps unsurprisingly, this gem comes from a TV pundit.

The talking head in question this time is the lamentable Glenn Beck, CNN's go-to ‘irreverent conservative’ voice. In an online Op-Ed, Beck details his miserable experience with doctors after getting surgery and works very hard to turn his displeasure into an argument against health care reform—with little success.

Long story short, Beck had surgery on his butt, things went horribly awry, and he was seriously medicated in order to dull the pain. The combination of drugs Beck received “took [him] to an incredibly dark place...Every time I closed my eyes…I would see horrific, unimaginable images of death and after two and a half days…I was literally suicidal. It felt like there was no hope…”

Beck’s despair went more or less ignored by doctors, who he says "treated [me] more like a number than a patient. At times, staff members literally turned their back on my cries of pain and pleas for help. In one case a nurse even stood by tapping his fingers as if he was bored while my tiny wife struggled to lift me off a waiting room couch."

This is unsettling stuff that I wouldn't wish even on Glenn Beck. Predictably, but not unjustly, Beck uses his experience as a launching pad to assert the importance of compassion and bedside manner in medical professionals. Here here! But then Beck really, really jumps the tracks:

Health Wonk Review Is Up

Health Wonk Review is up here. This compendium of some of the best health care posts of the past two weeks is well worth reading. 

This week, Bob Laszewski of Health Care Policy and Marketplace Review  is our host, and he is highlighting pieces that examine some of the candidates’ health care plans (Joe Padua on John McCain, Jason Shafrin on all of the Democrats, and Anthony Wright comparing candidates on both sides of the aisle) as well as California’s effort at health reform (Brian Klepper is skeptical). He also calls attention to Roy Poses' expose of yet another greedy CFO on Health Care Renewal.  But I’m not going to try to list everything here. Check out Health Care Policy and Marketplace Review yourself—I suspect you’ll wind up putting it on your “favorites” list.

Turf Wars: Doctors Battle Over Some Procedures While Avoiding Others

Earlier this week the Happy Hospitalist, an internist who works full-time in a hospital,  published a behind-the scenes look at the “turf wars” that doctors fight when it comes to performing certain very lucrative procedures.  Colonoscopies, for example, pay nicely, and doctors vie to do them. Bone marrow biopsies, on the other hand, belong to the group of procedures he labels the “red headed step children” of hospital care:  they’re relatively time-consuming and just don’t pay very well. As a result, the (usually) Happy Hospitalist explains, he often has a very tough time finding a specialist willing to perform one of these procedures for a patient.

Let me preface his story by pointing out that Medicare’s fee-for-service payment schedule—which has become the basis for most private insurers’ payments as well—is set and updated by a proprietary, and rather secretive advisory committee, the RVS Update Committee (or RUC).

I’ll tell you more about the RUC in the post below (“Who Decides How Much To Pay Specialists?”)  But first, read the Happy Hospitalist’s story. (Note, throughout the piece, I have inserted definitions of medical terms, in brackets.)

From: The Happy Hospitalist
TUESDAY, JANUARY 8, 2008 
“Red Headed Step Children”

“In the world of procedures, all procedures are not created equal. And when that happens, the turf wars begin. I can assure you, in just about every hospital in this country, behind the scenes politics go hand in hand about who has the right the perform what. The battles usually ensue in those procedures that are economically worth while to the doctor or group of doctors

Who Decides How Much Specialists Are Paid?

If you’ve read the post above about specialists vying to do lucrative procedures like colonoscopies-- while avoiding equally time-consuming procedures that just don’t pay as well--you might have wondered: who sets and updates the fees for each procedure?

The answer: a Medicare advisory committee called the RVS Update Committee (or RUC).  The RUC flies under the radar. It’s quite secretive and many people have never heard of it. Yet it is enormously powerful. It sets the prices for Medicare’s fee-for-service payment schedule, a price-list that has become the basis for most private insurers’ payments as well.

Who is on the RUC? It’s dominated by specialists. So, it should come as no surprise that a specialist’s time is deemed to be worth far more than an internist’s or a family doctor’s time.  An article in the June 2007 Annals of Internal Medicine provides a quick example.

In 2005, the Medicare fee for a typical 25- to 30-minute office visit to a primary care physician in Chicago was $89.64 for a patient with a complex medical condition (Current Procedural Terminology [CPT] code 99214). By contrast, Medicare’s fee for a gastroenterologist in the outpatient department of a Chicago hospital performing a colonoscopy (CPT code 45378)--which also takes about 30 minutes—was $226.63.  And if the specialist performed the procedure in his own office, where he pays for equipment and nursing time, he could charge Medicare $422.90 for his thirty minutes.  (Of course the primary care physician also has to pay for staff and equipment, though the equipment may not be as expensive.) 

Health Care and—Not or—the Economy

Yesterday Maggie posted on how economic insecurity and health care are in fact related issues. I agree 100 percent, and wanted to take the opportunity to show that the American people concur. Health care costs and economic insecurity aren’t in competition for public mindshare—according to poll responses at least, the two are coupled.

Every year Gallup asks voters “Are you generally satisfied or dissatisfied with the total cost of health care in this country?" Check out the results from 2001 through 2007 below.

The trend toward being more worried about price of health care is clear. And inherently, cost worries are economic issues.

But the connection between economics and health care goes well beyond this logical argument—you can actually see the two linked in polls. Take a look at the graphs below (click both to enlarge them), from a Kaiser Family Foundation report published last month. Since 2004, Kaiser has been asking respondents how worried they are about a set of potential problems. The first set of bars shows that flagging incomes and high health care costs are the two major concerns that people say they are “very worried” about. This makes sense: the less confident you are about your purchasing power, the more worried you’ll be about buying essentials like health coverage.

The Newest Last-Place Finish for U.S. Health Care

Many people—okay, mostly conservative politicos—like to say that the U.S. has the best health care system in the world. Time and again, those of us in the reality-based community offer a legion of evidence as to why this isn’t true; the ethno-centrists wag their fingers and repeat their refrain; and so the cycle continues.

But recent numbers from the Commonwealth Fund should put a stop to this cycle: the U.S. health care system places last in the world when it comes to stopping preventable deaths.  In other words, we spend more but accomplish less—does that sound like success to you?

The new study, funded by Commonwealth and appearing in the Jan/Feb ’08 issue of Health Affairs, looks at “deaths from certain causes before age 75 that are potentially preventable with timely and effective health care.” Relevant causes of death include diabetes mellitus, intestinal infectious diseases, whooping cough, childhood respiratory diseases, leukemia and others.

The authors, both from the London School of Hygiene and Tropical Medicine, found that America’s success in staving off these health problems has decreased over time. Between 1997/1998 and 2002/2003, preventable deaths fell by an average of 16 percent in all 19 industrialized countries considered; but the decline in the U.S. was only 4 percent. In 97/98, “the U.S. ranked 15th out of the 19 countries on this measure—ahead of only Finland, Portugal, the United Kingdom, and Ireland—with a rate of 114.7 deaths per 100,000 people. 

“By 2002–03, the U.S. fell to last place, with 109.7 per 100,000. In the leading countries, mortality rates per 100,000 people [for 2002-2003] were 64.8 in France, 71.2 in Japan, and 71.3 in Australia.” [see graph below, courtesy of Commonwealth]

Election Watch—Reframing the Issues: It’s the Economy Stupid!

On Gooznews last week, Merrill Goozner made a provocative argument:

“…the latest polls show the economy has eclipsed health care as the most important domestic issue among voters. Even the health care-oriented Kaiser Family Foundation's latest poll shows the number of Americans who name health care as their primary concern fell to 30 percent in early December from 38 percent just two months earlier. When offered a list of possible issues the candidates ought to address, the economy had pulled even with health care.

“The escalating fear that the nation may be heading into a recession because of the sub-prime mortgage meltdown and sky-high gas prices has certainly played a role in the turnabout. In that sense, 2008 is beginning to look a lot like 1992. The year before that election, health care dominated the national discussion after Harrison Wofford used the issue to win a surprise victory in a special Senate election in Pennsylvania. But by the time Arkansas Gov. Bill Clinton stormed to victory in the primaries, ‘it's the economy, stupid’ had become the Democratic standard bearer's watchword.”

Merrill may be right: certainly health care didn’t seem to be the driving issue in Iowa, and I doubt it will determine the results in New Hampshire. (See my last post on Iowa and New Hampshire.)

And I agree that, by November, the economy may well be the paramount issue. We are heading into a recession.

How Are Iowa and New Hampshire Different From the Rest of the Country?

When it comes to health care, the citizens of Iowa and New Hampshire are different from you and me: they enjoy higher quality yet much more affordable health care than citizens in virtually any other state. This may help explain why health care just hasn’t seemed to be a pivotal issue in these early primaries.

The chart below (click the image for a bigger version in a new window), published in Health Affairs in 2004, rates the quality of  health care state by state (see vertical axis) while also revealing how much Medicare spends, on average, per beneficiary in each of the states each year. (See horizontal axis.) Spending has been adjusted to take into account inflation, differences in prices in different states, and differences in the age, sex and race of the Medicare population in each state.  States that spend most appear on the far right of the chart. States that provide the highest quality health care are clustered at the top.