Media Myths about Dr. Donald Berwick; Is There A Chance He Won’t Be Confirmed to Head Medicare & Medicaid?

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.

“It Will Take Ambition. And It Will Take Humility”

Atul Gawande gave the commencement speech at Stanford’s School of Medicine this year. Below, the speech, which was published in the New Yorker http://www.newyorker.com/online/blogs/newsdesk/2010/06/gawande-stanford-speech.html    

 

Summary:  In his speech, Gawande congratulated the class for ignoring their elders: “You come into medicine and science at a time of radical transition. You have met the older doctors and scientists who tell the pollsters that they wouldn’t choose their profession if they were given the choice all over again. But you are the generation that was wise enough to ignore them: for what you are hearing is the pain of people experiencing an utter transformation of their world.”

 

Most people do not enjoy radical change that turns their world upside down—and doctors are no exception.  “Doctors and scientists are now being asked to accept a new understanding of what great medicine requires,” Gawande explains. “It is not just the focus of an individual artisan-specialist, however skilled and caring.

 

 “The volume and complexity of what doctors need to know has grown beyond our capacity as individuals,” he warns. “Diagnosis and treatment of most conditions require complex steps and considerations, and often multiple people and technologies . . . . We’ve been obsessed in medicine with having the best drugs, the best devices, the best specialists, but we’ve paid little attention to how to make them fit together well.”  And because our system is not well coordinated, “more than forty per cent of patients with common conditions like coronary artery disease, stroke, or asthma receive incomplete or inappropriate care in our communities.”

 

He tells the story of a patient who lost all of his fingers and all of his toes because each doctor thought that another doctor involved in his care had given him the vaccine he needed.

Patient Safety Advocates Give Plan to Reform Medical Residency a Failing Grade

Accreditation Group’s Proposal on Resident Physician WorkHours Do Not Measure Up to Institute of Medicine Recommendations

Summary: As regular HealthBeat readers know, resident sometimes work 30 hours shifts. In 2008, the Institute of Medicine (IOM) recommended capping shifts at 16 hours, saying that longer shifts are unsafe for patients and residents themselves. Sleep deprivation is likely to lead to errors; residents acknowledge that lack of sleep has caused them to make mistakes that harm, and sometimes even kill patients. Exhaustion also affects how they feel about their patients. I have posted about this here. The IOM also noted that in some cases, residents need better supervision. I told the story of what happened to 15-year-old Lewis Blackman earlier this month.

Should We Lift the Retirement Age and Make Social Security and Medicare More “Progressive”?

Speaking at a Third Way event earlier this week, House Majority Leader Steny H. Hoyer (MD) had this to say about the deficit:

“On the spending side, we could and should consider a higher retirement age, or one pegged to lifespan; more progressive Social Security and Medicare benefits; and a stronger safety net for the Americans who need it most. “

On the face of it, lifting the retirement age makes sense. Americans are living longer, so they could retire later and still enjoy their golden years.

Except—only some of us are living longer.

Are Doctors Really Boycotting Medicare?

As 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?

The New York Daily News Offers Medical Advice To Its Readers—Contradicting the American Cancer Society

As regular HealthBeat readers know, I’ve been writing about the risks of PSA testing for early-stage prostate cancer since I launched this blog in 2007. 

The American Cancer Society does not support routine PSA testing for prostate cancer. Testing often leads to unnecessary treatment which, in turn, leads to life-changing side effects—namely incontinence and impotence. Moreover, early detection does not guarantee a cure. See these posts on HeathBeat: here and here. Finally, see this very informative NYT story that I posted about in 2008.

Nevertheless, The New York Daily News has once again launched a campaign urging men to take advantage of FREE PSA testing. (Of course the treatment that follows won’t be free, but that’s another story.)

One Family’s Story

I urge everyone to read “What Broke My Father’s Heart” in the Sunday New York Times Magazine, a superb first-person narrative by Katy Butler http://www.nytimes.com/2010/06/20/magazine/20pacemaker-t.html?ref=magazine

Butler describes how our money-driven medical industrial complex has begun to dictate how we die—even if we think we have done our best to make our wishes known.

Here are a few excerpts:

My parents “had signed living wills and durable power-of-attorney documents for health care. My mother, who watched friends die slowly of cancer, had an underlined copy of the Hemlock Society’s “Final Exit” in her bookcase. Even so, I watched them lose control of their lives to a set of perverse financial incentives — for cardiologists, hospitals and especially the manufacturers of advanced medical devices — skewed to promote maximum treatment. At a point hard to precisely define, they stopped being beneficiaries of the war on sudden death and became its victims.”

I would add: Be careful of what you wish for.  Too many Americans set out to “beat death” without realizing that death is not the worst thing that can happen to you:

 “Thanks to advanced medical technologies,” Butler writes, “elderly people now survive repeated health crises that once killed them, and so the ‘oldest old’ have become the nation’s most rapidly growing age group. Nearly a third of Americans over 85 have dementia (a condition whose prevalence rises in direct relationship to longevity). Half need help with at least one practical, life-sustaining activity, like getting dressed or making breakfast. Even though a capable woman was hired to give my dad showers, my 77-year-old mother found herself on duty more than 80 hours a week. Her blood pressure rose and her weight fell. On a routine visit to Dr. Fales, she burst into tears. She was put on sleeping pills and antidepressants.

Let Me Say It Again: Congress Will Not Slash Medicare Payments to Physicians

Summary: Opponents of reform will continue to pretend that at some point in the future, “Obama-care” will mean drastic across-the-board cuts in reimbursements to doctors who take Medicare patients, forcing many to abandon their patients. The Senate’s bi-partisan action on Friday should serve as a reminder that this just isn’t true. Congress never has and never will implement the blind cuts that the SGR formula calls for. The SGR has nothing to do with the reform legislation President Obama signed in March. In fact, the Affordable Care Act hikes payments to many physicians.

 Friday, June 18, the Senate aproved a plan that blocks a 21 percent cut in Medicare payments to physicians; the axe was scheduled to fall that day. Leadership on both sides of the aisle pushed for the reprieve; it will remain in place for six months. The measure will now need to be considered by the House, which in May approved a fix that would last longer. If the House agrees that the cut should not be implemented--and it is all but certain that it will--the 21 percent cut wil be replaced with a 2.2 percent pay hike. The bill will not add to the deficit. The proposal is fully offset by changes in Medicare billing regulations, antifraud provisions and the tightening of some pension rules, eliminating Republican objections that it would push the federal government deeper into debt. The only question is whether the House will demand a full repeal of the SGR formula which calls for a 21 percent cut, or at least, a much longer repreive.

In six months, Congress will have to consider the matter once again, just as it has ever year since 2003.  This is the third time this year that Congress has averted Draconian cuts to physician’s payments. What, you might wonder, is going on?  Here is the back-story:  in 1997, Congress enacted a so-called "sustainable growth rate" (SGR) mechanism to keep Medicare physician reimbursement rates in check. Congress has never allowed the full cuts called for under the SGR formula to take effect and it never will.

Why don’t legislators simply repeal the cuts to doctors’ fees that they have been postponing for years?  Why just put off the measure for another six months? 

Don’t Confuse Pete Peterson’s Desire to Slash Medicare with the Goals of HealthCare Reform –Part 1

Summary:  Deficit Hawks want to slash both Medicare and Social Security, and they seem to be in control of the President’s National Commission on Fiscal Responsibility and Reform. Hovering in the wings, aging mogul Pete Peterson is eager to help them do the job.

 The Peter G. Peterson Foundation is spending lavishly to exploit anxiety about the economy –to a point that Americans now name “the deficit” as the No. 1 threat to America’s future. He uses that fear to justify cutting "entitlement programs."

Meanwhile, Peterson is posing as a liberal as he attempts to make common cause with health care reformers. In the process, he is blurring the very important distinction between what the health care legislation would do to reform Medicare, and his own proposals. Reformers would expand effective care while reducing waste; Peterson would shift costs to Medicare beneficiaries while restricting the number of Americans eligible for the Medicare program.

The irony is that cutting domestic spending is exactly what we shouldn’t do in the midst of this economic crisis. As George Soros explains, when you’re skidding you have to turn into the skid.

What Many Liberals Don’t Understand About Health-Care Reform

Both liberals and conservative critics have charged that the health reform legislation that President Obama signed this spring focuses mainly on insurance coverage, and does little to rein in the spiraling cost of health care. This isn’t true. But the legislation is dense-- and, as usual, the truth is more complicated than a lie. There is no single “fix” that will “break the curve” of health care inflation. The Affordable Care Act (ACA) contains multiple provisions that open the door to cost containment in myriad ways.

 In today’s issue of The New England Journal of Medicine (NEJM), Peter Orszag, director of the White House Office of Management and Budget (OMB) and OMB special health advisor Zeke Emmanuel explain how the bill will make Medicare more affordable:   “Perhaps most fundamentally,” they write, “the ACA recognizes that reform, particularly changing the delivery system, is not a one-time event. It is an ongoing, evolutionary process requiring continuous adjustment. The ACA therefore establishes a number of institutions that can respond in a flexible and dynamic way to changes in the health care system.”

What is most exciting is that under the new legislation, Congressional lobbyists will not be able to block the process: “The secretary of health and human services (HHS) is empowered to expand successful pilot programs without the need for additional legislation.”

Below excerpts from their “Perspective” in the June 16 NEJM: