Part 1

“It’s like whack-a-mole,” a Dartmouth researcher commented in a recent e-mail. He was referring to that fact that, as Congress moves closer to the day when it will reconcile House and Senate versions of health-care reform legislation, critics seem to be popping up everywhere to question more than two decades of  Dartmouth University research which exposes the waste in our health care system. 

Dartmouth’s researchers can barely keep up. No sooner have they responded to one Op-ed than another mole appears, attempting to undermine the credibility of the research.

Until very recently, “The Dartmouth Research” has been widely accepted. The work done by Drs. Jack Wennberg, Elliott Fisher and their colleagues has established the fact that in some regions of the country, patients receive far more aggressive and expensive care than in other communities. Yet—and here’s the shocker—when patients receive more intensive care, outcomes are no better. Sometimes they are worse.

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OK, so apparently after Joe Wilson was publicly rebuked for calling the President a liar, the administration decided rather than ignore the outburst, they’d throw him—and his fellow xenophobes, a bone. Obama has made it clear from the start that undocumented immigrants will not have access to any government programs or subsidies for health care. But over the weekend, the administration decided to go further and released this statement about limiting access to the proposed health exchanges on Monday:

“Under President Obama's plan, undocumented immigrants would not be allowed to enter the exchange. People who are lawfully present in this country would be able to participate in the exchange.”

That statement, which echoes a provision that is included in the newly-released Senate Finance Committee’s version of health reform, means that even undocumented workers who want to pay out of pocket for health insurance—with no government subsidy—will be denied access to the exchanges.

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The nice thing about Bloomberg News is that no one accuses it of being a left-wing rag.

So when Bloomberg spotlights a  report from the Institute of Medicine (IOM)  that  counters “stingy” estimates from the Congressional Budget Office on how much health care reform could save, it’s worth paying attention. The analysis from the institute’s working group on health costs reveals that the type of reform that Congressional progressives support would save  “five times the amount that CBO acknowledges” according to Bloomberg’s Tim Mullaney.

“The report will help bolster the argument that covering the nation’s 46 million uninsured won’t bust the budget . . .”

According to Bloomberg, the IOM working group plans to release a preliminary version of its report “by about September 20 . . . to ensure its findings contribute to the debate in Congress . . . , with a more comprehensive paper to follow.”

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Most people don't know what is in the House bill to reform health care, yet it is, I think, close to what the Obama administration originally envisioned. When the House and Senate bills are reconciled, how close will the final product be to the House bill?  Hard to tell, but I see it as a benchmark for progressive reform. While it’s not perfect, it represents a very good start. Over the next three years, as it’s fleshed out, details are filled in, and Medicare is reformed in ways that enhances the quality of care, eliminates hazardous waste and reins in costs, it could become an excellent plan.  But you can’t root for it if you don’t know what’s in it.

As I mentioned yesterday, the House Committee on Education and Labor has put together an interactive graphic to help people figure out how “America’s Affordable Health Choices Act,” HR3200 would affect them.  Again here’s the link. Click on it, and you can find out what the legislation would mean for you, whether you’re self-employed, uninsured, on Medicare, or have employer-based insurance. It also tells you how the bill would affect both large and small employers.

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Jack Coulehan is a physician and senior fellow at the Center for Medical Humanities, Compassionate Care, and Bioethics at Stony Brook University in Stony Brook, NY. He describes himself as “not only an experienced physician, but also an advocate—in fact, a teacher—of standard-of-care practice.”

But he was no match for the vagaries of the hospital emergency room.

In the most recent issue of Health Affairs, Coulehan writes about hearing tales from friends about being “caught in a web of excessive and unnecessary medical testing” when they went to their doctors for seemingly routine problems. Although sympathetic, he couldn't really relate.

He goes on to say, “Many of the tales also included delays in receiving their test results, frequent referrals to specialists, and poor coordination among health professionals. Naturally, I’d express sympathy or outrage, whichever the speaker seemed to expect, but internally I’d pat myself on the back. I felt fortunate that there was absolutely no way I’d ever be stuck in such a scenario.”

Well, it turns out that Coulehan was wrong. A bout with self-diagnosed shingles on Easter Sunday sent him to the emergency room “to confirm the diagnosis and get my prescriptions.” Instead, Coulehan ended up spending all day in the ER, seeing an ophthalmologist and neurologist, having two MRIs and a CT scan and racking up $9,000 in medical charges.

The tale he tells of “the Great ER Caper,” provides a clear example of the  “unnecessary testing, inappropriate consultation, and uncoordinated care” that are rampant in hospital ERs and throughout the health care system. Chastened by this experience of winding up as “a poster boy for excessive medicine,” Coulehan asks;

“How can we make stories like mine less common? The only way is an approach to health care reform that encourages well-coordinated, standard-of-care practice and one that simultaneously discourages the irrational shotgun approach to medicine.”

To combat all the rumors and myths out there, the House Committee on Education & Labor has  put together an interactive graphic to help folks figure out how the House Plan would effect them and their employers.

It looks excellent. Comments?

Last week I was travelling, and not able to respond to all of your comments. Though I did begin writing replies in the car, while driving down to D.C.

This is not as dangerous as it sounds—my husband was doing the driving. And we drove from our home in Manhattan to the hotel in D.C. in just four hours!

 Is this as dangerous as it sounds? Hard to say. In all of his years of driving my husband has never had an accident. And we’re certainly safer than if I were driving. (I tend to start thinking . . .  about healthcare, the problems, possible solutions  . . .)  

But all you really need to know is that you’re not likely to encounter me on a highway near you, and if you commented on a recent post, you’ll probably find my reply.

Secondly, readers have e-mailed me to ask whether individuals can buy the DVD of Money-Driven Medicine, the  documentary based on my book, produced by Alex Gibney (“Enron: The Smartest Guys In the Room” and “Taxi to the Dark Side,” which won an Academy Award for best documentary in 2007. 

Originally, the information on the website where you can buy the DVD (www.moneydrivenmedicine.org) was unclear.  But the fact is that individuals can buy the DVD from the film’s distributor for $49.95.  The distributor is hoping that you might then host a home screening—invite five or six friends over to watch the film, much the way you might invite them for dinner. (Or “pass the hat” and everyone can chip in for the film.)  Full disclosure: I have nothing to do with pricing, and will not profit from sales of DVDs. The distributor owns the rights.

The Book : Money-Driven Medicine: The Real Reason That Healthcare Cost so Much is now once again available, one-day shipping  When Bill Moyers showed an abridged version of the film on his PBS show, Bill Moyers Journal, demand for the book soared, and the publisher, Harper/Collins, ran out of copies. They immediately went into a second printing, and books are now available on www.barnesandnoble.com to be  shipped the next day.  Amazon.com also now hax copies, though their website hasn’t yet updated to say how quickly they can ship them.  

Correction: I’m afraid I created some confusion on the “Truth Squad: The House Bill Would Prevent Medical Bankruptcies” post below ( https://healthbeatblog.com/2009/09/truth-squad-the-house-bill-would-prevent-medical-bankruptcies.html)

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The U.S. Census Department announced yesterday that in 2008, 46.3 million Americans did not have health insurance, a “not significant” increase from the 45.7 million uninsured the year before. But dig a little deeper into the survey—and understand its limitations—and you’ll find that the 2009 Current Population Survey (CPS) actually provides a compelling snapshot of the country in recession. Besides the new data on the uninsured, the survey also includes information on household income (down 3.6% between 2007 and 2008) and the poverty rate (13.2%, up from 12.5% in 2007).

Taking a closer look at the data also reveals which populations are most likely to be uninsured and where the need for reform is felt most strongly. The Census survey finds that 1.6 million more adults lost their health coverage between 2007 and 2008. The opposite is true for children; expansions in CHIP and also increases in federal matching funds for Medicaid coverage for kids have left fewer vulnerable and uninsured.

“The good news for kids is that Medicaid and CHIP are absorbing some of the uninsured and that’s pretty amazing given many states’ economic problems,” says Genevieve Kenney, a Senior Fellow and health economist at the Urban Institute. But, she goes on to say, “For adults, the public programs aren’t really there to catch them. This reflects real gaps in the safety net.”

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Last night, President Obama gave an excellent speech. He was clear; he was passionate. I did not expect him to draw a line in the sand regarding the public insurance option. That would only have given his opponents a clear target. The decision about the public option will be made at the very end of this process when the House and Senate bills are reconciled. There were no real surprises in the president’s speech. What stood out was the reaction to what he said:

“You lie!”

Representative Joe Wilson’s unprecedented outburst underlined the extraordinary hostility that President Obama faced last night.

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A story in today’s New York Times begins: “For years, health policy experts have said health care spending is much higher in New York City and Boston because doctors and hospitals there provide more services, practicing medicine in a more intensive way. But new government data show that Medicare costs per patient in those cities are slightly below the national average when the numbers are adjusted for the cost of living and other factors.”

The Times goes on to explain that President Obama “says that the nation could save huge sums if all doctors and hospitals were as efficient as those in lower-cost states like Iowa, Minnesota, Washington and Wisconsin. Lawmakers from those states have reached an agreement with House Democratic leaders that would increase federal Medicare payments to health providers in their states. Higher-cost states, which could see their Medicare payments reduced, are fighting back.”

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