Nortin Hadler on How to Win the Healthcare Lottery Without Buying a Ticket

Below an excerpt from an essay by Dr. Nortin Hadlerprofessor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and an attending rheumatologist at University of North Carolina Hospitals. He is the author of "Worried Sick: A Prescription for Health in an Overtreated America," "The Last Well Person," and “Stabbed in the Back.”

I am always delighted when Hadler contributes to HealthBeat. He is willing to tell the truth about medical evidence and comparative effectiveness research– even when candor may not be popular. You don’t have to agree with him, but without question, you should read his work.   Hadler is not a pundit offering one man’s opinion:  his writing is studded with footnotes and links to rigorous medical research.

This post is excerpted from a piece which originally appeared on ABC.com, Health Care Reform: The Difference Between Rationing and Rational.“There  Hadler explains why, if a doctor recommends angioplasty, you should ask some questions. At the end of the post, you will find my “Note” on what I find the most intriguing aspect of Hadler’s essay: how to win the healthcare lottery without buying a ticket.


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Medical Education: Reforming How We Train Doctors

 

Below, another provocative story from Pulse–voices from the heart of medicine, an online magazine of personal experience in health care.  The piece raised some questions in my mind about how we train medical students. You’ll find my comments at the end. (To join the Pulse community, and receive every issue, online, at no cost, click here.)

First, Do No Harm

By Alison Block

It's one of my earliest memories: I'm wrestling with my brother, and I'm losing, because I'm five and he's seven, and he's bigger and stronger than I am. So I bite him, hard.

Instantly I know I've crossed some sort of line, and I employ my most primitive defense mechanism, shouting out, "He bit me! Jon bit me!" I feel shame, because I am old enough to know it is wrong to hurt people–and to lie.

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Instead of Tort Reform, Why Not Focus On Reducing Actual Malpractice?

In his State of the Union speech in January, President Barack Obama appeared to throw a bone to congressional Republicans when he said, "I am willing to look at other ideas to bring down [health care] costs, including one that Republicans suggested last year – medical malpractice reform to rein in frivolous lawsuits." There were scattered cheers and clapping from the audience, but since then no more details have emerged from the President.

To those who need reminding, reforming medical malpractice is a cornerstone of the Republican version of health care redesign; one of the few concrete ideas they’ve put forth for reducing the nation’s $2.1 trillion health care bill. The idea, recently championed also by Gov. Andrew Cuomo’s (D-NY) Medicaid redesign team, is to cap non-economic damages (compensation for future pain, suffering and loss of function) at $250,000 in all cases. Some 30 states already have variations of medical malpractice caps and other tort reforms in place. According to the Congressional Budget Office, the effect of these caps on reducing the number of lawsuits or the practice of “defensive medicine” (unnecessary tests and procedures doctors order to avoid being sued) has been at best, equivocal. Where they have had a moderate effect is on lowering malpractice insurance premiums for certain types of physicians and increasing their supply in some geographic areas.

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Berwick Update: “Republicans Won” (Baucus); “Focusing on the Job” (Berwick)

"The Senate will never vote to confirm Dr. Donald Berwick as CMS administrator", Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee told reporters earlier today. According to Modern HealthCAre, Baucus said that he has discussed Berwick's nomination with Republican senators and they plan to oppose Berwick under any circumstances.

“Republicans won,” he said about the nomination. 

 For his part, Berwick told reporters that he was grateful for the White House support he has received since 42 Republican senators wrote President Barack Obama last week to demand that he withdraw Berwick from consideration. Earlier today, Modern HealthCare quoted Berwick saying that he is "focusing on the job."

For Republicans to flatly refuse to consider a presidential nominee without letting him testify at a confirmation hearing signals something far short of "bipartisan cooperation." 

Do they actuallly have that much power? 

Perhaps. But arrogance can be dangerous.

I find it hard to imagine that the Obama administration will roll over and say "Okay. We'll let forty-two senators decide who heads up Medicare." The gang of 42 do not  even represent a majority of the 100 elected representatives in the Senate. But of course, 60 votes would be needed to break a filibuster, which is why the group, led by Sen. Orrin Hatch, believe that they have the clout to pull this off.  

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Berwick Targeted By Lynch Mob; CMS Director “Abandoned” by the Administration?

When President Obama named Dr. Donald Berwick to head the Centers for Medicare and Medicaid (CMS) last March, I wrote this:

“Most who know Berwick describe him a ‘visionary’ and a ‘healer,’ a man able to survey the fragments of a broken health care system and imagine how they could be made whole.  He’s a revolutionary, but he doesn’t rattle cages. He’s not arrogant, and he’s not advocating a government takeover of U.S. health care.”

To understand what I meant, view these clips from the film, Money-Driven Medicine, where Berwick speaks about the need for healthcare reform. Soft-spoken and charismatic, Berwick is as passionate as he is original. His style is colloquial, intimate, and ultimately absolutely riveting. He draws you into his vision, moving your mind from where it was to where it could be.

And now, it appears that we are going to lose him. Thursday, 42 Senators delivered a letter to President Obama demanding that he withdraw his support for Berwick to head CMS. The Boston pediatrician and co-founder of the Institute for Health Care Improvement (IHI) had received a temporary appointment in July while Congress was on vacation. President Obama re-nominated him in January. But Berwick still needs to be confirmed by the Senate, or he will have to leave his post at the end of this year.

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The True Victims Of Fetal Pain Laws

Danielle and Robb Deaver are living proof of the awful reality of Nebraska’s ill-conceived “fetal pain” law. The law, which took effect last October and is the only one of its kind in America, prohibits abortions in the state after the 20th week of pregnancy. It is based on the discredited notion that a fetus may feel pain at that stage of development. Physicians who break the law face felony charges that could result in five years in prison and a $10,000 fine.

Danielle Deaver, a nurse, was 22 weeks pregnant with her second child when her water broke. Doctors determined that her membranes had ruptured and there wasn’t enough amniotic fluid to support the fetus.But because of Nebraska’s law, Deaver could not obtain an abortion and was forced to live through “10 excruciating days” waiting for her extremely premature fetus to be born even though doctors were sure it would never survive. When finally delivered, the one-pound, ten-ounce baby girl gasped and struggled for air, dying 15 minutes later in her mother’s arms. Tragically, the Deavers had sought an abortion to avoid just such an excruciating end; they were concerned that the infant would suffer while it died, trying to breathe.

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The FDA “Has a Chat” With Plastic Surgeons

It’s always good to hear about the FDA being proactive. Below, a post by Jim Edwards, writing on BNET’s  “Placebo Effect, ” tells how the FDA reacted when surgeons began advising doctors that they shouldn’t use the word “cancer” when talking about a form of breast cancer associated with breast implants.  

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When is breast cancer not “cancer,” not malignant and not a tumor? When you’re a plastic surgeon trade group funded by implant makers Allergan (AGN) and Johnson & Johnson (JNJ), according to an exchange of letters between watchdog group Public Citizen and the FDA.

In January, the FDA warned of an unusual type of breast cancer associated with implants. Allergan, which makes the Natrelle brand of implants, responded by denying that implants were linked to cancer and by denying that anaplastic large cell lymphoma (ALCL) is “cancer” per se.

On Feb. 3, the presidents of two cosmetic surgery trade groups — The American Society of Plastic Surgeons and The American Society for Aesthetic Plastic Surgery held a members-only webinar where they advised doctors on what to say to worried women. Dr. Phil Haeck, president of ASPS, said ALCL wasn’t a “cancer” but a “condition”:

“[Y]es it’s classically a malignant tumor, but it has such a benign course that when we were discussing ways to talk to the media we decided that we would call this a condition  . . .not a tumor, not a disease and certainly not a malignancy. . . .

“And I would recommend that you use the same terms with your patients rather than disturb them by saying  ‘this is a cancer.’   . . .The best word is “this is a condition.’  If you develop this condition here’s how we are going to treat it, the way we are going to diagnose this condition is this . .. .

And I think you are certainly justified, with what we know now, in downplaying the malignant potential of these [cancers].

The FDA responded by having a little chat with the two groups and the video of the webinar has magically disappeared from the groups’ web sites.

Following the money

It is probably not a coincidence that ASPSS and ASAPS repeated the cancer-denial line first promulgated by Allergan: Both organizations have received funding from the company. ASPSS has also received funding from Allergan’s main competitor, J&J, which makes the Mentor implant line. (Mentor’s reaction to the FDA warning was more muted than Allergan’s but its statement also avoided mentioning the C-word.)

Both Allergan and J&J fund provide funds for ASPSS, as noted on its web site.

At ASAPS, Allergan’s funding is more indirect. It has supplied research grants through ASAPS’ research arm, the Aesthetic Surgery Education and Research Foundation. You can see those grant award announcements by searching for “Allergan” here.

The two groups ought to be ashamed of themselves. It is one thing to take funding from drug and device companies . .  . . But the groups ought to represent the medical expertise of the healthcare providers who are their members, not the PR agendas of two companies who are afraid they may lose money from too much blunt but accurate talk about breast cancer.

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Primary Care and the National Health Service Corps: Finding Physicians “Who Will Go Where No One Else Will Go”

Roughly 65 million Americans live in places where there are at least 2,000 potential patients for each lonely physician. No surprise, these tend to be impoverished rural regions, or depressed inner cities. We call them “underserved areas.”

If we paid medical schools to train more primary care physicians, would they migrate to these areas? Probably not. Experience shows that if we increase residency slots, physicians continue to flock to the same popular, well-served areas where most prefer to settle: Manhattan, Boston, Boca Raton. . .

It should come as no surprise that relatively few med students elect to set up a practice in rural Mississippi, Detroit, or the South Bronx—unless they are returning home. As I have written in the past, research reveals that students coming from low-income communities frequently feel a commitment to those communities.  

Many—not all, but enough—want to go back. But these days, given the sky-high cost of medical school tuition, combined with the nearly perfect test scores and GPAs that med schools require, very few students who attended public school in a small town in Tennessee wind up becoming M.D.s. 
Yet health care reform guarantees that waiting rooms full of formerly uninsured low-income patients will be looking for health care. According to the Harvard Medical School, an additional 17,000 primary care health professionals will be needed in underserved areas. Skeptics suggest that reformers have promised more than we can possibly afford. How will we funnel more general practitioners to areas where there already are too few physicians? How much will we have to pay to lure them there?

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Reality Check: Haley Barbour, BMWs and Medicaid Recipients

It seems old lies never die—especially when it comes to entitlement programs for the poor.

In the contentious debate over how to reduce spending in state Medicaid programs, Mississippi Gov. Haley Barbour (R) insisted that one solution for his state is to have Medicaid recipients pay a larger share of their medication costs, saying, "We have people pull up at the pharmacy window in a BMW and say they can't afford their co-payment."

That ridiculous comment harkens back to Ronald Reagan’s use of "Cadillac-driving welfare queens," to refer to a fictitious cadre of black mothers living the high life while collecting public assistance. Tinged with racial undertones, Reagan’s characterization of welfare recipients—including a 1976 reference to the typical food-stamp user in the South being  a ‘strapping young buck’ buying T-bone steaks—helped bolster support for his overall attack on social welfare.

As Steve Benen writes in Washington Monthly today, “In other words, when Barbour claims ‘we have people’ who pick up prescriptions in Mississippi in a BMW — as if this is somehow common — he's lying.

“But I suspect Barbour doesn't much care. The point of a quote like that one isn't to draw attention to a legitimate policy concern; it's to appeal to right-wing voters on an emotional level.”

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Medicaid Reform: States Clamor For “Relief and Flexibility”

States want flexibility in implementing the health care law, and President Obama told the National Governor’s Association yesterday that he supported a bipartisan bill that would allow states to apply for innovation waivers in 2014 instead of in 2017, as currently written into the health law. This bill, introduced last year by Sens. Ron Wyden (D-Ore.) and Scott Brown (R-Mass.) would allow states to opt out of major provisions like the individual mandate and pursue alternative routes to reform—as long as they meet the same coverage targets as the federal plan. Kathleen Sebelius, Secretary of the Department of Health and Human Services, called this action “another crucial step in empowering states to lead,” giving Vermont, for example, a chance to try a single-payer approach at the same time that Utah was developing a market-driven insurance exchange.

Meanwhile, Obama’s announcement was greeted far less enthusiastically by conservative critics of the health law who are intent on repealing the entire legislation, not making it more innovative. “Mandating many of the same requirements, this plan would treat states as agents of the very law these governors are running away from,” said Michael Steel, spokesman for Speaker John Boehner. “A better approach would be working with reform-minded governors to give states more flexibility to lower health care costs immediately by, for example, fixing costly federal regulations on Medicaid.” This chilly reception doesn’t bode well for the Wyden-Brown bill’s chances in the House.

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