Schwitzer health news blog

Gawande gets us talking

I'm honored to be included in a list of commenters recruited by the Kaiser Health News Service to react to Atul Gawande's New Yorker piece on "The Cost Conundrum."

KHN writes:

"The ... article is now being called one of the most influential health care stories in recent memory. The New York Times reported that President Obama made it required reading for his staff and cited it at a meeting with Democratic senators last week. His budget chief, Peter Orszag, has written two blog posts about the article. Health and Human Services Secretary Kathleen Sebelius referred to it in a speech at the John F. Kennedy School of Government last week. Lawmakers on the Hill also are discussing it. Congressman Jim Cooper, D-Tenn., for instance, says the article has "shifted perceptions on the health care industry."

Then they asked the following to comment - an interesting range of perspectives:

• Robert Blendon, Professor of Health Policy and Political Analysis, Harvard School of Public Health and John F. Kennedy School of Government

• Greg Scandlen, Senior Fellow, Heartland Institute

• Joseph W. Stubbs, President, American College of Physicians

• E. Linda Villarreal, Past President of the Hidalgo-Starr County Medical Society, Internist in Edinburg, Texas

• and me.

By the way, if you want to learn about health policy and if you haven't been following the recently-launched Kaiser Health News Service, you should be.

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Funding for comparative effectiveness research just got a big boost

That's how Keith Winstein of the WSJ framed the news that "aggressive use of expensive diabetes drugs and medical devices called stents did no better than cheaper treatments at preventing deaths, heart attacks or strokes in a large study of diabetics with heart disease."

He wrote that it was the latest study "to humble fancy new treatments by finding them no better than older medicines at preventing the deadly consequences of major diseases. The results add to a debate about alleged overuse of stents."

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Public willing to make tough health care choices

The non-profit Center for Healthcare Decisions just completed a study, What Matters Most, documenting what 1,200 Californians believe are the most important services for coverage by health insurance.

Len Nichols of the New America Foundation said, "The findings could have national influence as Congress begins deliberation on major health reform….this is perhaps the best representation we have of the public's view on a lot of these complicated issues."

“Leaders often assume that the public is not willing or capable of setting priorities for health insurance,” center executive director Marge Ginsburg said in a press release. “The fact is, when given a chance to speak up, the public is fully capable of making decisions that affect them as patients, as taxpayers and as citizens who want a role in developing a fair and affordable healthcare system.”

What did the survey show? "One thing we heard loud and clear is that the public is not willing to share high costs," Ginsburg said. "Most people said they would elect to take more areas of coverage away rather than paying higher premiums and copays. Everybody's very conscious of the fact that if you make cost sharing too expensive, it's counter-productive. It doesn't matter what wonderful things you offer in the way of coverage. If people can't afford it, they just won't use it," Ginsburg said.

The What Matters Most report can be downloaded here.

Stories on the survey appeared in California Healthline.org and in the Sacramento Business Journal.

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Patients struggle to find quality health care info

Yale cardiologist Harlan Krumholz has an important piece in the Washington Post, "Which Docs Measure Up?" (alternatively headlined online as "We Need A Consumer Reports for Doctors.") Excerpt:

"Need a new hip? A hernia repair? You're out of luck if you want to look at a doctor's track record or an institution's success rates. Results vary by surgeon and by hospital; you just have no way of knowing which one is best. And often, neither do they."

He frames the article, though, around the story of a patient who turned to him (a cardiologist) for advice after being diagnosed with prostate cancer.

"This patient had nowhere to turn to figure out which doctors and hospitals had the best results and the lowest risk of these complications. His dilemma is the same one that virtually every patient -- and the entire health-care system -- is facing: How can you measure quality in an area in which your life may be at stake?"

Of course what Krumholz didn't address was the fact that maybe this man's life wasn't at stake. A diagnosis of prostate cancer may not mean a death sentence. It may mean that you've been labeled with a "cancer" that wouldn't have killed you and that you really didn't need to know about.

What happened to the guy? Krumholz concludes:

"He went to a doctor his internist recommended. He heard that the doctor used a fancy new robotic surgery device and assumed that this meant that he was good. Six months later, he occasionally loses control of his bladder, and his sexual function is not what it was. He is left wondering whether he made the right choice. Meanwhile his experience is not being tracked to help the next person choose or the surgeon and the hospital improve."

Ah, the robot. I've found newspaper headlines that promote it in a cheerleading fashion:

• Robot doctor - surgery of tomorrow

• Da Vinci puts magical touch on the prostate

• Cancer survivors meet lifesaving surgical robot

• Robotic surgeon's hands never tremble

• Da Vinci is code for faster recovery

• Surgical Maestro

• DA VINCI ROBOT IS SURGERY WORK OF ART

• Hospital hopes robot surgery will lure patients

The last one may come closest to the truth.

And, as Krumholz points out in his Post article, how are patients to be guided? The headlines about "which docs measure up" or "we need a Consumer Reports for doctors" do not do justice to the broader discussion of quality measurement, inexplicable variations in health care across the US, and profound uncertainties that exist in much of the underlying medical science.

But Krumholz didn't write the headline, and he should be applauded for his important article - and the Post should be applauded for publishing it.

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7 million more uninsured by 2010

New projections in an article in Health Affairs.

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Battle for the soul of American medicine

Wow, what an article by Atul Gawande in the June 1 issue of The New Yorker.

He visits McAllen, Texas, "the most expensive town in the most expensive country for health care in the world."

There are dozens of vital themes in the article:

• Nobody there seemed to know that they were cost outliers.
• Everyone seemed to blame someone else for being cost outliers.
• Except one surgeon who said, "Come on, We all kow these arguments are bullshit. There is overutilization here, pure and simple."
• Doctors owning strip malls, imaging centers, surgery centers...with "entrepeneurial spirit." One surgeon said, "It's a machine, my friend."
• "Medicine has become a pig trough here," one surgeon said. "We took a wrong turn when doctors stopped being doctors and became businessmen."

Gawande concludes:

"Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world."

This is a must-read.

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Single-payer blues

If you missed Bill Moyers' Journal last night on health care reform, it's available online and it was an important discussion - the likes of which we don't get often enough in the public sphere.

Single-payer advocates Dr. David Himmelstein and Dr. Sidney Wolfe joined Moyers for a look at why single-payer possibilities just aren't on the table in Washington, aren't represented around the table of those making the plans, and aren't covered much by journalism.

Excerpt:

MOYERS: I am puzzled as a journalist as to why this subject of single-payer, whether one is for it or against it, seems totally out of the debate in Washington. It's just not on the table. And it's not in the- on the radar screen of the press. Why do you think that is?

DR. SIDNEY WOLFE: I think the reason is, unfortunately, simple and frightening. Which is the power of the health insurance industry. Whereas, only about one out of 14 people trust the insurance industry as being honest and trustworthy.

BILL MOYERS: That's a poll?

DR. SIDNEY WOLFE: It's a Harris poll last fall. One out of 14 people think that the health insurance industry is honest and trustworthy. On the other hand, in Washington, they're in bed with the health insurance industry. Just as Wall Street and the banks have bought the Congress to get what they want in terms of the bailout, the health insurance industry has bought and influenced members of Congress and the President so much that they don't even consider the possibility of a plan that doesn't have a health insurance industry.

DR. DAVID HIMMELSTEIN: That's the big problem here is people want to find a solution that they can get through without a big fight with the insurance industry. Unfortunately it's economically and medically nonsensical - you can't actually have a health care program that works, if you keep the insurance industry alive.

Watch the entire program and/or read the entire transcript online. It's worth your effort to hear more about something you don't hear enough about these days.

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Kaiser health care reform gateway page

Of all the many interesting offerings on a new Kaiser Family Foundation "gateway" website on health care reform, I especially like the timeline on the history of health care reform efforts in this country - a sorry and sordid story.

Some of my undergrad students attempted a similar timeline on a student project this past semester. I'm proud of their commitment to learning from history.

Other things Kaiser promotes on its new site:

* An interactive tool for comparing major health care reform proposals, including President Obama’s Principles for Health Reform and congressional proposals from Senator Baucus, the Senate Finance Committee, Senators Wyden and Bennett, and Representatives Conyers, Dingell, and Stark. The side-by-side allows users to choose which proposals and characteristics to compare, including coverage, cost containment and financing. The side-by-side will be regularly updated to reflect changes in the proposals and to incorporate major new proposals.
* A series of Explaining Health Care Reform Briefs providing an overview of key topics and concepts being discussed in health reform efforts. The initial three Briefs explore “what is health insurance”, “what is an employer pay or play requirement”, and “what are health insurance exchanges”.
* A glossary providing simple, straightforward definitions of key terms to assist in understanding the concepts included in health reform proposals.

Check it out.

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