Schwitzer health news blog

Demand for true health care reform

A new Wall Street Journal/NBC News poll shows health care at the top of Americans' priority list, with 76% calling increased access and lower costs "an absolute priority" for 2006.

The Journal reports that "The Bush administration's much-heralded prescription-drug benefit under Medicare has yielded scant political benefit. Unfavorable views of the benefit outnumber positive marks by 31%-15%, with the rest having no opinion. Nearly eight of 10 senior citizens call it 'too complicated and confusing.' "

Will an emphasis on "consumer-driven health care" and health savings accounts address access, lower costs and senior prescription drug problems?

Editorials anticipate State of Union HSA push

Thanks to American Health Line, a product of the National Journal, for rounding up newspaper editorial comments on the President's pending push for expansion of health savings accounts:

* Baltimore Sun: "Making health care choices is not like buying an automobile -- nor should it be" -- but Bush in his State of the Union address on Tuesday is expected to argue that "Americans would be getting more value for the billions of dollars the nation spends on health care if comparative shopping was part of the process," a Sun editorial states. According to the Sun, the proposal does not address "the major source of expense, which is the relatively small share of the population who are very sick," and would "discourage preventive care and screenings ... that can save the big bucks of late-stage treatments for patients whose ailments are caught early" (Baltimore Sun, 1/30).

* New York Times Magazine: Bush has a "general absence of ambition" on the issue of health care and has focused on "modest initiatives that don't begin to address the structural deficiencies in the system," reporter Matt Bai writes in an NYT Magazine opinion piece. He writes that HSAs, which "are the centerpiece" of the health care proposals that Bush plans to announce in his State of the Union address, "will help some families afford their doctors' bills -- but that's assuming they already have enough money to both buy a plan and save extra money in the first place." According to Bai, "That Bush embraces such proposals, at the expense of more lasting reform, fits the larger pattern of his presidency." (Bai, New York Times Magazine, 1/29).

* Washington Post: Proposals by Bush to make U.S. residents more responsible health care consumers through increased out-of-pocket costs are "misguided," in part because most "consumers aren't equipped to distinguish between good medical service and bad," a Post editorial states. According to the editorial, "Bush may be about to go after the wrong target using the wrong tool" (Washington Post, 1/30).

Conflicts of interest in academic medical centers

A group of top health care thought leaders published a plan in this week's Journal of the American Medical Association for academic medical centers to "take the lead in eliminating the conflicts of interest that still characterize the relationship between physicians and the health care industry."

The group writes: "Although physician groups, the manufacturers, and the federal government have instituted self-regulation of marketing, research in the psychology and social science of gift receipt and giving indicates that current controls will not satisfactorily protect the interests of patients. More stringent regulation is necessary, including the elimination or modification of common practices related to small gifts, pharmaceutical samples, continuing medical education, funds for physician travel, speakers bureaus, ghostwriting, and consulting and research contracts."

But Merrill Goozner at the Center for Science in the Public Interest, who has tackled health care conflict of interest questions since leaving newsroom journalism, writes in his blog that the group didn't go far enough. For example, he writes: "First, by focusing on the nation's academic medical centers, they ignore the fact that most of the drug and device industries' marketing practices are aimed at the nation's nearly one million practicing physicians, not the elite in the nation's medical schools. ... Moreover, the practice of medicine is heavily influenced by clinical practice guidelines written by professional associations or patient advocacy groups like the American Society of Clinical Oncologists or the American Heart Association. ... While many academicians sit on these guideline writing committees and most groups have strong conflict-of-interest disclosure requirements, industry exerts extraordinary influence over the guidelines either through direct funding of these groups or ongoing relationships with members of the guideline-writing committees. This proposal does nothing to liberate the writing of clinical practice guidelines from industry influence."

Op-ed pieces slam Medicare drug "benefit"

American HealthLine, a publication of The National Journal tracked these op-ed pieces:

* Kansas City Star: "It is hard to believe that even the federal government could have done such a terrible job launching the new Medicare drug benefit," a Star editorial states, adding, "What a disaster." According to the editorial, the U.S. "needs a drug benefit that is easier for people to use, more logical in its coverage and far less generous to the drug companies" (Kansas City Star, 1/24).

* Springfield Republican: The Medicare prescription drug benefit "has been a disaster," and the "problems with the ... program cannot be easily fixed" because they are "systemic, not cosmetic," a Republican editorial states. (Springfield Republican, 1/22).

* Washington Examiner: The "new program was ... supposed to save the states money in matching funds," but "now state officials are fronting the money themselves, only to be told that they will have to go through the private insurers to get it back because Medicare officials have no statutory authority to pay them directly," an Examiner editorial states. The editorial adds, "No way! Medicare officials failed to make sure this overly complicated program was working properly, so it's up to them to make sure that localities are reimbursed for covering their mistake" (Washington Examiner, 1/23).

* Washington Post: "Many of the problems that have plagued the new Medicare drug benefit since its launch ... were not only predictable but predicted," a Post editorial states. Although the Medicare prescription drug benefit "could succeed -- or at least become cheaper and more efficient with time" -- the program "hasn't gotten off to a good start, and the politicians who legislated it should try hard to understand why," the editorial concludes (Washington Post, 1/24).

Opinion Pieces

* Maine Rep. Hannah Pingree (D), Bangor Daily News: "Congress and the president need to take a hard look at this new benefit and decide whether this plan, which benefits drug companies and insurance companies over American seniors, is working." (Pingree, Bangor Daily News, 1/21).

* Rev. Jesse Jackson, Chicago Sun-Times: "Hundreds of thousands of our most vulnerable citizens have found themselves cut off from prescriptions paid for by Medicaid and unable to obtain essential medicines," Jackson writes in a Sun-Times opinion piece. According to Jackson, "Seniors are paying the price in confusion, catastrophic drug cutoffs and escalating drug prices," as "American taxpayers pay for the costliest health system in the world, with the worst health results in the industrial world." (Jackson, Chicago Sun-Times, 1/24).

Bush push for more health savings accounts

This weekend, President Bush, in his weekly radio address, said he plans to help reduce health care costs by pushing for an expansion of health savings accounts.

"I decided this is a national issue that requires a national response," Bush said, adding that the government must ensure "that health care is available and affordable." One wonders whether he just realized this.

An expansion of health savings accounts means different things to different observers. Drew Altman, president and CEO of the Kaiser Family Foundation, told the LA Times, "We may be looking at the start of a fundamental shift in what we mean by health insurance, from a system where we share risks to one where it's up to individuals to make their own deals and bear their own risks."

This week Minnesota Public Radio presents a week-long series on health savings accounts and so-called "consumer-driven health care." (I am interviewed in one of the segments).

Pharma whistleblower lawsuit

On his always newsworthy blog, Merrill Goozner wrote this week about a drug company whistle-blower lawsuit that was unsealed in a Maine courtroom last week. Gooz wrote:

"The suit was filed by Paul McDermott, a former drug salesman for Genentech, Inc. While the focus of his complaint was Rituxan, an anti-cancer drug heavily promoted for use with rheumatoid arthritis patients by its co-sponsors, Genentech and Biogen-Idec, its explosive charges are an indictment of the drug industry’s entire system for reaching out to physicians to promote the off-label use of drugs. The suit called the system an illegal kickback scheme aimed at defrauding Medicare.

McDermott was eventually fired after asking for a transfer. Genentech and Biogen are contesting the charges. Though the case was brought under the Civil War era False Claims Act, which returns two-thirds of any recovery to the government, the Bush administration’s Justice Department last week refused to intervene in the case."

Health care in 2006

In an e-mail newsletter, former U.S. Senator David Durenberger (R- Minn.), now head of the National Institute on Health Policy offered some perspectives on health care in 2006:

“…the tragic truth is that the health system is making too much money and demanding more, while consumers, employers and taxpayers are looking at going bankrupt or bare. Since I first became involved 35 years ago, policymakers have been complaining that the system costs too much. But now, for the first time, we are recognizing it also produces too little. Miracles? Yes. Good health and consistently high quality medicine? No.

…How much is enough? It appears that no one cares about finding the answer. We are too busy laying the future of cost containment off on the consumer and on pay-for-performance. Everyone (even public employment) is now moving to high-deductible, catastrophic insurance in which the seller sets the rules and the buyer is left to figure out how to pay for ‘what’ because there aren’t any ‘prices’ to compare in the medical market.

National insurance monopolies are right around the corner fed by national employers buying national accounts and all playing by a dizzying number of local rules. As we all get more of ‘our skin in their game,’ these health insurance plans are becoming banks and credit card companies with profit margins swelling even beyond that of their usurious commercial financing counterparts. …

What’s puzzling to people like me is why we would turn the Medicare and Medicaid programs over to an industry which has shown so little inclination to cover the uninsured. Instead they create uninsured with pre-existing condition exclusions or premium pricing. They require most hospitals to take all comers whether they get paid or not. Many doctors do the same.”

And, yes, he writes: “The 2006 election does have a lot to do with health policy.”

MN Republicans criticize feds for Medicare Rx plan

Two Minnesota Republicans in recent days blasted the Bush administration's Medicare prescription drug "benefit" because of how it forced states to solve many citizens' problems with the program.

The Star Tribune reports that "hundreds of low-income Minnesotans have been affected by a computer glitch that mistakenly cut them off from access to subsidized drugs." Governor Tim Pawlenty said the feds' implementation of the program has been "awful." He also said, "I don't think it was well thought-out to begin with," calling the plan "almost mind-numbing" in design.

The Star Tribune also reports that Senator Norm Coleman (R-Minn.) called the program's problems "inexcusable" in a letter to Medicare administrator Dr. Mark McClellan.

Pharma's so-called "educational" grants

A Senate Finance Committee investigation into educational grants awarded by pharmaceutical companies to physicians and groups that promote medications for unapproved uses has found the "payments are growing rapidly," the New York Times reports - now almost $1.5 billion a year.

"It's hard to see how you could call some of these grants 'educational,'" committee Chair Chuck Grassley (R-Iowa) said. Sen. Max Baucus (D-Mont.), ranking member of the committee, added, "If drug companies are crossing the line with these grants and influencing providers to make treatment decisions they might not otherwise make, that's a problem, and we're going to tackle that."

The Times reports that FDA regulations have "long allowed drug companies to give educational grants to individuals or groups that discuss or promote off-label uses." But feds "have been investigating whether these activities have strayed beyond educational purposes and violated antikickback statutes or resulted in the government's spending money in its Medicare and Medicaid health programs for prescriptions that were not warranted." The Times reports that more than half of all prescriptions written nationwide are for off-label uses.

A tale of two health care systems

A Minneapolis Star Tribune editorial:

A woman visiting England recently had a fingernail pulled out by its roots in a car door. She was taken to a local clinic in Cornwall, then referred to a regional hospital in the National Health Service system. The hospital was crowded and a little run-down. The woman had to wait a fair amount of time. But finally she was seen by a doctor who cleaned the wound and explained the nail had to be replaced and held securely or it might not regrow. That was done and she was provided pain medications, then discharged. Cost to her: not one pence.

In whose lifetime will the wasteful United States finally join the civilized world, where universal care is recognized as both less expensive and morally required? England's NHS has many flaws; the United States shouldn't follow that model. But universal care with an American flavor must come. Stories like Ruby Cintron's tell why.

Mixed message on Medicare drug coverage

Market choices versus big government-run taxpayer-subsidized programs.

The Medicare drug coverage program is an experiment in trying to do both simultaneously, according to an essay in the Wall Street Journal.

An excerpt: "This market-friendly expansion of Medicare doesn't seem to be paying political dividends or attracting much consumer interest so far. 'This is a test case,' says Jonathan Oberlander, a University of North Carolina political scientist. 'It's a theory in search of population, and they've found the wrong population. A lot of what you're seeing is what happens when you try to turn seniors and people with disabilities into computer-linked consumers. It's insanity.'

Much of the problem may be that the drug benefit reflects political compromises that overlook lessons learned elsewhere about how consumers cope with an overwhelming array of choices."

The science and politics of colorectal cancer screening

Two Norwegian researchers offer a very thoughtful essay in the current PLoS Medicine.

They describe different countries' differing policies on colorectal cancer screening -- from simply screening everyone or none at all. Meantime, the benefits of screening and the ideal screening method, have not been clearly established.

Or nations could do what the Finns have done -- with a stepwise, randomized trial, allowing evaluation of its fecal occult blood test screening program after five years before deciding what their next step of action should be. The authors write: "The people behind the Finnish strategy deserve credit for persuading their politicians to choose this cautious, stepwise model, and the politicians and health authorities deserve credit for listening. In the Finnish model, half of each age cohort is randomised to screening or no screening. The Finnish model must have required a lot of explanation to authorities that this approach was clearly the best way to proceed. It was, of course, risky for politicians to voluntarily throw away half (or more) of their target candidate supporters by declaring, in essence, 'We believe in (colorectal cancer) screening, but aren't sure about it, and half of you will be offered screening while the other half will not.' "

Finally, with a shot at celebrities like Katie Couric who use their platform to promote screenings for which not all the evidence is in, the authors write: "Health policymakers must also remain sceptical of the role of celebrity endorsements. Communication on complex decisions such as cancer screening, with an aim to inform rather than persuade, is not an obvious task for celebrities."