No doubt you have seen some of the numbers about the assault that corporate lobbyists mounted to try to block health care reform: In 2009 spending on health-care-related lobbying and TV advertising topped $700 million. The Center for Public Integrity reports that much of that money funded the 4,525 healthcare lobbyists who swarmed the capitol– eight for every member of Congress. You couldn’t beat them off with a stick. Of course, many legislators didn’t want to.

Yet despite that extravagant effort, National Journal Contributing Editor Eliza Newlin Carney questions whether the health care industry’s lobbyists got good value for their dollars.

 “For health industry players . . .  it's unclear whether all that lobbying, advertising and check-writing yielded much,” Carney writes. “At bottom, partisan rifts and fickle political winds have done more to derail proposed health care changes than any lobbying campaign. That stands in contrast to President Clinton’s failed health reform plan 16 years ago, which ran aground in part because of deft insurance industry lobbying.”
That last sentence made me pause. I remember 1994, and it’s true. Lobbyists played a much, much larger role in maiming, and then killing reform.

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Abortion was such a hot-button issue in the battle over health reform that it threatened to derail the process on multiple occasions—including the final push to get the legislation through Congress.

Supporters of comprehensive reproductive health benefits stood by and watched in frustration as the Hyde Amendment’s draconian ban on federal funding for abortion was extended even to private insurance plans available through the new exchanges. Their only solace was that the restrictions in the legislation would at least temporarily tamp down the furor over “taxpayer-funded abortions.” And with the legislation mandating increased funding for family planning and sex education, the nation could instead focus on the other strategies Obama—and seemingly many Americans—support to reduce unwanted pregnancy.

Now it’s became clear that the abortion fight is far from over; anti-choice activists are far from mollified and are eager to push their agenda far beyond health care reform. Today, Nebraska’s governor signed into law legislation banning abortions that occur in that state at or after 20 weeks gestation, using a new standard that assumes fetuses feel pain after this point. Gov. Dave Heineman also signed a law requiring women who seek abortions to receive screening and counseling for vague “risk factors” both before and after the procedure. Failure to identify such a “risk factor” could result in a doctor facing a penalty of $10,000.

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MYTH #1:  Reform legislation calls for a 21% cut in Medicare payments to physicians.

FACT:  First, the 21% cut has nothing to do with reform legislation. Secondly, it is never going to happen.

Back in 1997 Congress passed legislation which said that if Medicare spending on physicians exceeds a complicated “Sustainable Growth Rate” (SGR) formula in a given year, Medicare fees to all doctors would be trimmed the next year. Since then, Congress actually followed the SGR formula only once. Every other year, it postponed the cuts until the following year—which is why the accumulated postponed cuts now exceed 22%.

The SGR rule was, from the beginning, a crude solution to health-care inflation. We don’t want to whack all doctors’ fees across the board. Any adjustments should be made with a scalpel, not an axe. We know that Medicare pays some doctors (primary care docs, gerontologists, palliative care specialists and general surgeons) too little while overpaying some specialists for certain services.

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    Pulse: An Invitation to HealthBeat Readers

From time to time, I have quoted stories from Pulse: Voices from the Heart of Medicine, on HeathBeat. This free, online magazine publishes both narratives and poetry. Most are written by patients or health care providers. All are based on true events.

I believe that medical narrative is becoming an important part of health care reform.  Too often, when talking about healthcare, we focus only on the numbers, and ignore the stories.  As Dr. Donald Berwick, President Obama’s candidate to head the Centers for Medicare and Medicaid points out, “our measurements will mislead us if we forget the stories.” Indeed, "measurement can pluck the heart from a story.”

Pulse aims to capture the experience of receiving or giving care, and it does this very well. The authenticity of the writing is striking and the editing is excellent. Full disclosure: Paul Gross the magazine’s editor and founder,  is a friend.

But I am not alone in noticing this small magazine. Just last week, the Washington Post called attention to Pulse: “Subscribers to the free online magazine Pulse (http://www.pulsemagazine.org) receive a weekly essay or poem about health care . . . . Paul Gross, a physician and assistant professor at the Albert Einstein College of Medicine at Yeshiva University in New York, launched Pulse nearly two years ago, frustrated with the chasm between the scientific studies in medical journals and what it's like to practice medicine on a daily basis. The missing link turned out to be the voices of patients, providers and educators.” http://www.washingtonpost.com/wp-dyn/content/article/2010/03/29/AR2010032902931.html 

Pulse has now asked subscribers to invite friends to sign up for this free on-line magazine. So I am extending the invitation to all HealthBeat readers. To subscribe, please click here http://www.pulsemagazine.org/signup.cfm

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Over at The Health Care Blog Lisa Gaultieri, an Adjunct Clinical Professor in the Health Communication Program at Tufts University School of Medicine observes that, too often, the computer becomes a barrier between the clinician and the patient. She offers insight into how to integrate a laptop into the conversation.

David Leonhardt had a piece in the New York Times today called “In Medicine, the Power of No,”  that focuses on reducing health care costs by scaling back our current “do everything possible” approach to care. “Deep down, Americans tend to believe that more care is better care,” he writes, “We recoil from efforts to restrict care.”

The era of managed care revealed a pretty clear picture of how Americans feel about forced limits on the care they can receive. More recently, Conservatives fomented panic with their attacks on health reform that focused on the looming threat of government rationing of care—including “death panels” and refusals for surgery and treatments based on cost alone. Leonhardt writes;

“From an economic perspective, health reform will fail if we can’t sometimes push back against the try-anything instinct. The new agencies will be hounded by accusations of rationing, and Medicare’s long-term budget deficit will grow.

“So figuring out how we can say no may be the single toughest and most important task facing the people who will be in charge of carrying out reform. ‘Being able to say no,’ Dr. Alan Garber of Stanford says, ‘is the heart of the issue.’”

I agree that a sea-change is needed in how Americans view health care—but I think it would be a mistake to assume that health care costs are out of control because consumers are clamoring for more and more care and need to be reined in. 

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The New America Foundation’s Joann Kenen has posted an insightful piece on how some innovative medical centers deal with medical mistakes: Rather than stonewalling patients and relatives, they “Disclose. Apologize and Fix.”

I’ve written in the past about how “Sorry Works.”   (You’ll find part 2 of the post here. ) 

But as Kenen points out, this is not just about apologizing.  Or as she puts it, it’s not enough to say: “Something went wrong. We’re sorry. Here’s a check. Ciao.”

Moreover, she notes that “there are many obstacles to expanding this model. The best known examples [of places where full disclosure has proved successful are], like the University of Michigan or the Lexington VA center, staff models. The doctors are part of the hospital staff and everybody is covered by the same malpractice insurer. That’s not true in most hospitals, and there can be numerous doctors, numerous insurers, all with their own take on what happened and whether to disclose — or deny.”

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Over the past two years, I have met the leaders of a relatively new physicians’ organization, the National Physicians’ Alliance, and I have been impressed by their agenda. Quite simply, they put patients first.  Here is their mission statement:

“United across medical specialties, the National Physicians Alliance was founded in 2005 to restore physicians' primary emphasis on the core values of the profession: service, integrity, and advocacy.  The NPA works to improve health and well being, and to ensure equitable, affordable, high quality health care for all people. The NPA strictly refuses financial entanglements with the pharmaceutical and biomedical industries.  To learn more, visit this site.

I would describe the NPA as “the new AMA.”  The NPA has been growing quickly, and it is stepping up to make its voice heard. 

At the end of March, when the Association of American Physicians and Surgeons (AAPS) announced that it was going to sue to try to overturn health care reform on constitutional grounds, I asked Valerie Arkoosh, president of the NPA,  if the organization  would like to comment.

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Back pain is endemic: It affects 8 out of every 10 people at one point in their lives. Americans spent some $86 billion in 2005 on doctor’s visits, surgery, imaging, and drugs to treat back and neck pain—and costs continue to rise each year. Despite being ubiquitous—and an enormous drain on medical resources—back pain continues to be poorly treated as well as over-treated. Recent research has shown that doctors consistently fail to follow accepted guidelines in treating their patients; ordering X-rays and MRIs when they aren’t useful, prescribing expensive prescription drugs when over-the-counter pain relievers would work just as well and resorting to surgery without evidence that it will actually relieve pain and disability.

The trend, unfortunately, is continuing. A new study published in this week’s issue of the Journal of the American Medical Association found that although the rate of lower-back surgery among older Americans had declined slightly between 2002 and 2007, the rate of the most complex, medically risky and most expensive type of lower back surgery increased 15-fold (from under 1% of operations to 14.6%) during this same time period. There is little upside to this increase in intervention: Besides driving up health care costs, the authors found that overuse of the expensive, risky technologies put patients at increased risk of death and life-threatening complications without providing a corresponding increase in pain relief or mobility.

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This is the first in a series of posts that
will try to dispel the myths and reveal the facts about the reform
legislation. What will reform mean for insurers, hospitals, doctors,
Medicare patients, seniors who are now on Medicare Advantage, Medicaid patients
and state budgets? Who wins and who loses?

You may be surprised by some of the answers.
The legislation is rich in details that have been ignored.  Liberals
as well as conservatives are making assumptions that just don’t square with the
facts.

Below,
I focus on the impact that reform will
have on the private insurance industry–and on the industry’s customers.

MYTH # 1:  Health Care Reform represents a “boon” for
private insurers.

FACT:  It is s
true that, beginning in 2014, virtually all Americans will be required to buy
insurance, or pay a fine. But while insurers will pick up a boatload of new
customers, many will be refugees from a health care system that treated
them poorly. Think of the
boat as a life raft. These could be very expensive customers. 

Moreover,
between now and 2014, insurers will face some serious financial hits. These
new regulations will make our health care system fairer and more
affordable. But the rules also suggest that going forward, for-profit
health insurance may not be a viable business–unless these
companies learn how to keep patients healthy, while insisting on value for
health care dollars. Insurers that over-pay drug-makers or hospitals will find
that they can no longer turn a profit by simply passing the added expense along
in the form of higher premiums. 

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