Healthy Policy

Top Health Policy Stories of 2005

The Commonwealth Fund and Kaiser bring you the top health policy stories of 2005:

The leading vote-getters were:

• The number of uninsured continues to grow, hitting nearly 46 million, with another 16 million reported to be "underinsured."

• Hurricane Katrina draws dramatic attention to holes in the nation's health care safety net.

• Registration begins for new Medicare prescription drug benefit, despite widely reported confusion among seniors over the myriad choices for coverage.

• New cross-national studies add to evidence that U.S. health care system, the most expensive in the world, doesn't perform as well as that of several other industrialized nations on various clinical indicators and in reported patient experiences.

• Health care costs continue to increase, putting increased pressure on consumers, particularly the growing number citing trouble paying off medical debt.

I've written on all of them except Katrina, click on the categories links to the right to read more.

Estimating malpractice costs

The Washington Post reports on a new realization from a recent study on malpractice costs:

The insurance industry has long argued that huge losses from malpractice suits -- now running more than $7 billion a year -- have forced it to hike malpractice premiums, which more than doubled last year in some cities and for some specialties.

But a new study by a consumer group shows that losses reported to state regulators -- the figures often cited by the industry -- were much larger than losses actually paid during a nine-year period.

The study, by the Foundation for Taxpayer and Consumer Rights, a Santa Monica, Calif., advocacy group, found that from 1986 to 1994 the industry reported to regulators losses of $39.6 billion but actually paid only $26.7 billion, 31 percent less. The losses were overstated in each of the nine years.

That's quite an overstatement when you're dealing with billions of dollars. But it appears one of the biggest problems in the malpractice puzzle is a lack of information:

Fueling frustration on all sides: a surprising lack of data available from the nation's patchwork system of state regulation. Two years ago, the Government Accountability Office studied the problem and said that although insurance losses "appeared to be the greatest contributor" to higher premiums, a "lack of comprehensive data . . . prevented us from fully analyzing the composition and causes of those losses." The study concluded that Congress "may want to encourage" state regulators to collect data on "the frequency, severity and causes of losses on medical malpractice claims."

Even how much doctors actually pay in premiums is not readily available. Annual rates are kept by individual state insurance departments, and all sides rely on an industry newsletter, Medical Liability Monitor, based in Chicago, to collect data.

With all the moaning and complaining about malpractice costs, why aren't doctors demanding more information? The article states that many malpractice insurance companies are owned by physician groups. Don't they have a stake in what's actually driving malpractice costs? Or maybe their best interests are served in claiming it's the size of the awards and limiting those at the expense of patients.

And costs aren't as high as we think -- go read my post on U.S. malpractice awards compared to other countries.

Knowledge is power, people.

Best of '05 -- Health Affairs Edition

The Health Law Prof Blog has the list of the most-read Health Affairs articles of this year. If you've got a subscription, the most-read list is a great resource. Head over to an article outside your usual health angle. For me, that'll be John Holahan and Arunabh Ghosh, "Understanding The Recent Growth In Medicaid Spending, 2000-2003".

Health spending abroad: it's not what you think

Ezra has a great post on Reinhardt and Hussey's Health Affairs paper on U.S. health spending and the rest of the world:

A lot of libertarian economists (Arnold Kling and the like) tend to argue that the high costs of care in America are a simple result of how much we pay for services. They, predictably, ascribe the sums to the awesome technologies and phenomenal operations we deploy. But it's more structural than that. In their (damn good) paper on the variance between US health spending and costs in other countries, Uwe Reinhardt, Peter Hussey, and Gerard Anderson explain.

According to the authors, higher costs can be attributed, in part, to health practitioner's wages and a fragmented delivery system that gives more market power to the supply side of the equation. Which puts a hole in arguments over technology, but lays open quite clearly that things like high deductible health plans (HDHPs) and other plans to shift cost to consumers won't make a huge difference. The increased spending vis a vis other nations is on the backs of doctor's and hospitals fees for care, as well as gaping holes in the delivery system that give them more market power. Integration of care within regions (and between them), coupled with larger payers with more power will help bring us back in line with the rest of the world.

UC continues the corruption parade

Via Health Care Renewal, more corruption comes to light in this wrap up of recent problems in the University of California system. The Santa Cruz campus is my alma mater (and one of the bullet points of shady dealings).

Former UC Provost MRC Greenwood was charged with violating conflict of interest policies by hiring Lynda Goff, a friend and business partner, first as an executive assistant, then in academic affairs at a salary of $192 K. In addition, Winston Doby, UC Vice President for Student Affairs, who reported to Greenwood, hired Greenwood's son into a specially created internship position. When these events came to light, the university launched an investigation, but permitted Greenwood to resign her administrative position before it was completed, agreeing to give Greenwood 15 months of leave at her $ 301 K salary (per the San Francisco Chronicle).

This caused major uproar on campus. The "friend and business partner" is actually (or at least was) Greenwood's lesbian partner, and when faculty (especially those non-tenured, who've gotten a bad deal with pay in the last five years) accused her of neoptism and misusing funds, Greenwood returned with claims of homophobia. Needless to say, a bad situation.

Then there's the debate over the salaries of top administrators:

The first was about lavish pay and other compensation given to many top UC administrators, while state support of the system shrunk, and fees paid by students grew. But UC leadership argued that high pay was needed to attract top quality executives.

This I'm actually somewhat sympathetic to. I know a UC administrator well, have stayed at their home and spoken with them at length about their position. This administrator, though well paid, would absolutely be making 2-3 times their salary at a private institution. Further, if you consider the cost of living in the majority of the UC's campuses -- Orange County, West LA, Santa Cruz, Santa Barbara, San Diego, Berkeley -- these administrators need substantial salaries. Now, in the context of budget crises and student fee increases (because I was out of state, my tuition increased 20% every single year), administrator's salaries should be tied to other wage increases. But this problem is part of our current corporate culture. Public universities have the privilege of making that unacceptable -- the rest of the private sector employees do not.

There's also problems with the liver transplant program at UC-Irvine (birth place of Ezra), so head over for the details.

Corruption and Medicine

Via the New York Times, the University of Medicine and Dentistry of New Jersey is in deep:

UMDNJ effectively becomes the first public university in the nation to be placed under federal oversight, according to a Justice Department spokesman in Washington. With its five regional campuses, more than 4,500 students and a $1.6 billion annual budget, UMDNJ is the nation's largest health care university.

If criminal charges had been brought, the university would be disqualified from receiving the federal aid that makes up much of its budget.

For nearly a year, federal agents have been investigating accusations that administrators at the university doled out patronage jobs and tens of millions of dollars in no-bid contracts to their political allies, sometimes for work that was not performed.

Visit Health Care Renewal, who's been following the case for awhile, for more.

In the meantime, I have a question for the seasoned health policy vets: there appears to be a large number of improper conduct events lately -- Vioxx, Guidant, Cleveland Clinic, Aubrey Blumsohn, and now UMDNJ. Are there more incidents than usual, or is this standard corruption fare?

Surgery Update

I'm officially two weeks out from surgery and things are going well. To be sure, there's good days and bad days. Half the time I feel like they didn't do anything to me, that I can throw off my crutches and do a jig. Then there's days like the last few, where it's become increasingly apparent that I'm allergic to the adhesive in the steri-strips (little white pieces of tape they put over the incision to protect it). Apparently only 1 out of 200 patients get this reaction and now my leg looks like it was branded by 20 steri-strips. Awesome, I beat the odds. (If you missed what they did to me, head over to this WebMD description of the procedure)

In other news, I ventured out of the house in the wheel chair for the first time yesterday. This led to some valuable realizations:

• Clothing stores represent huge headaches for wheelchairs. The reason is two fold: the racks are placed so close together you can't fit through, and you definitely can't turn around; clothing is often on high racks you can't reach or thumb through without serious neck strain

• Nordstrom (and other upper-scale department stores), however, is the best store ever to shop in when you have a wheelchair. The layout is incredibly spacious allowing for as much turning around as one desires, and hardly any of their clothing is up on high racks. Their staff is also very professional, and don't treat you like you're a starving African child (oh poor you in a wheelchair! let me look at you like your life is so terrible and like you're three!)

• Every door represents a problem. When you don't need walking assistance, you don't even notice the number of doors you go through in a given day. Once you're in a wheelchair (or crutches, for that matter), every door becomes literal -- it's closed to you! And it takes some work to get through.

• There are an unbelievable amount of rude people out there. My mom is struggling to hold open the door and push the wheelchair over the bump, and people just go around us through the other door and don't offer to help at all. That doesn't mean you need to run ahead through doors to open it and always be on the look-out, but pay some freaking attention to your surroundings. A little help is appreciated.

So, in sum: Nordstrom's is awesome, doors suck, and open the door for people with wheelchairs, for God's sake!

Bad News for Pharma Marches On

Health Care Renewal has an eloquent summary of Guidant's recent troubles, and what it means for patients:

Attorney General Elliot Spitzer has sued Guidant for fraud, charging it concealed defects in its implantable cardiac defibrillators (ICDs, devices that use electric shocks to the heart to attempt to restore normal rhythm). In summary:

• Guidant has admitted that it did not disclose information about defects in ICDs to doctors and patients.

• These ICDs are very expensive, costing about $25,000.

• Had the physicians and patients known prospectively that the ICDs were not as reliable as previously thought, they might have chosen not to implant them, and implanting such flawed defibrillators provided less benefit to the population of patients receiving them than they thought they would receive.

• Thus, by concealing the information, Guidant likely made more money and increased costs to the health care system, but decreased the benefits to patients.

It's as simple as that, folks. Go read the entire post for more of the story.

Labor and health care -- the start of a beautiful friendship?

The New York Times is all over labor and health care today. First is the news that transit workers will pay part of their insurance premiums for the first time ever:

The Metropolitan Transportation Authority and the transit workers' union announced a settlement yesterday in which the authority abandoned its demand for concessions on pensions and the union agreed to have all workers pay a portion of their health insurance premiums.

The agreement calls for transit workers to pay 1.5 percent of their wages toward the premiums, cutting into the raises they receive. That comes on top of the fines of slightly more than $1,000 that most transit workers face for participating in last week's illegal transit strike.

The settlement calls for raises of 3 percent in the deal's first year, 4 percent in the second year and 3.5 percent in the third year. The subway and bus workers' current base pay averages $47,000 a year, and with overtime, their average yearly earnings total $55,000.

"These were huge items for our membership," said Marvin W. Holland, a station cleaner and board member who voted to approve the contract. "If it took a strike to get it, so be it. I think this is an overwhelming success." The agreement on health premiums will save the authority nearly $32 million a year.

In the first year, if the average salary is $55,000, workers will pay $825 of their own health insurance premium. Given that the average annual premium for an individual is $610, that's no small concession.

Then there's this Robert Fitch op-ed decrying the labor movement and its stance on nationalized health care:

Most advocates of universal health care focus on the opposition of Republicans and insurance companies. But perhaps the most important factor keeping an overhaul off the national agenda is one that few Democrats acknowledge: most of Mr. Gettelfinger's fellow labor leaders don't support a single-payer system either.

The reason comes down to simple self-interest. The United Auto Workers is one of the few private-sector unions that doesn't run its own health plan. Rather, most have created huge companies to administer their workers' plans, giving them a large and often corrupt stake in the current system.

Except that he's about 10 years overdue, as Ezra writes over at TAPPED:

The union movement is changing. And it's not just the new guard. The older unions, UAW included, are rapidly realizing that the corporate welfare state they so lovingly constructed is readying to collapse, with them beneath it. Today, the transit workers grudgingly accepted a deal that cuts into health benefits -- they had no other choice. Corporations have established similar beachheads in the benefit packages at Ford, GM, Delphi, and countless others. Where Old Labor used to focus on preserving what they'd already won, the swift disintegration of those gains is forcing them to search out more durable delivery mechanisms for health care, pensions, and the like. Their hostile posture from decades back isn't sustainable, but unions aren't stubbornly clinging to it, something Fisk fails to mention. No reason to let facts obstruct a perfectly good point, I guess.

Moreover, the new breed of unions -- SEIU, UFCW and the other service and low-wage unions Fisk never mentions -- have long been enthusiastic supporters of national health care. UFCW's homepage is anchored by a photo of a grocery cashier saying:

“Bottom line: contract negotiations are all about health care now. Unless something happens for health care nationally, I don’t see it getting any better.”
--Laurie Piazza, Local 4289

At the end of the op-ed, Fitch claims:

The problem is getting American unions to fight for common concerns as opposed to narrow institutional interests. It may just be that a broad-scale union overhaul will have to precede one in American health care.

Many labor leaders know their decisions to block single-payer care in the past proved poisonous. Of the big three unified interest groups with the most influence on the nature of care in the U.S. (the AMA, insurance companies, and labor), labor is the only one we'll see defecting to single-payer anytime soon. If the UFCW is any indication, labor's put their finger in the air and felt which way the wind blows. Fighting to preserve the status quo when health costs are bringing down companies (and thus eliminating jobs) is no longer in their best interest.

Learning from Cerner

HIS Talk has a great post examining what really went wrong with Cerner's CPOE (computerized physician order entry) system. For those of us who strongly believe in the awesome potential of HIT, it's essential to know what went wrong, and what we can do better.

I'm glad they did the study, but it seems to me more of a "don't do what we did" lesson for hospitals, not an indictment of Millennium. I think their purpose was to raise the awareness of broad outcomes in a major system change and the article does a good job of that.

I'm always quick to jump in a vendor-bashing line, but anyone who sees this article as valid Cerner criticism is wrong, in my opinion. I doubt any other vendor would have done better. I doubt every Cerner implementation has these problems. I'm sure that the hospital would make better implement decisions if they were doing it over again, as would most CPOE early adopters.

Go read the original critique by the HIT expert -- it's a valuable discussion of the intricacies of HIT programming and hospital implementation and well worth your time.

Of Health Care and Politics

We all know federal and state governments are buckling under the cost of health benefits. But their priorities have become more than a little perverse:

As they prepared to send the spending cuts to the floor, Senate Majority Leader Bill Frist of Tennessee and his GOP lieutenants realized they were headed for defeat unless they secured one more vote. And to get that, Frist had to meet the asking price of one of two GOP senators, Norm Coleman of Minnesota or Gordon H. Smith of Oregon.

Smith vowed not to support the bill unless it was changed so that proposed savings on Medicaid, the federal healthcare program for the poor, were achieved at the expense of drug companies and other providers instead of coming in the form of lower benefits for Medicaid recipients.

Coleman's price for supporting the package was removing from the bill a provision that would have eliminated $30 million in subsidies for sugar beet growers, many of them in his home state.

In the end, sugar farmers got to keep their subsidy and Frist got Coleman's vote.

Politics as usual, right? Maybe, until you see this stat:

There were 568,000 Medicaid recipients in Minnesota last year, and 40,000 people whose livelihood depended on sugar beets.

That's just in Minnesota. 52 million people are covered by Medicaid nationwide. That means one out of every six folks in this country are on Medicaid. You really think one out of every six people in this country farms beets ?

But the fed's cuts go much further than trade-offs between sugar producers (who have a part in our obesity epidemic, for sure) and a Minnesota senator. 29 states saw a decrease in the number of federal dollars they received for Medicaid in 2006, and states like Missouri and Tennessee are making significant changes in eligibility and payments.

Some people will be knocked out of the system altogether and join the ranks of the uninsured. Others will just postpone care. Either way, it's a lose-lose situation. We're running out of short-term fixes for Medicaid. Its long-term fiscal health is in danger, and it needs a long-term solution -- one that addresses the problems of the entire health care system.

Tuesday Stuff

Morning HPites! I hope you had a great holiday and have returned to your various places of blog trolling safely. I, for one, am done eating for the next three months. Our house continues to be stuffed to the brim with all manner of stick-to-your-arteries goodies (you know, the kind that take months to spoil because they're so loaded with fat and preservatives?). If I see one more chocolate something or other....

Back in the med blogosphere, The Health Care Blog is hosting Grand Rounds, Best of '05 Edition. It's long, but well worth the requisite clicking around to see just how fabulous us med bloggers are.

And now for something completely different

The Washington Post has a great piece on weird news from 2005. My parents would read the weird news from the Kansas City Star to me and my sister after dinner, so I'm going to pass on the tradition electronically with a sampling of my favorites:

CROOKS WITH MONEY MANAGEMENT PROBLEMS (I) Police in Twin Falls, Idaho, confiscated almost $1 billion in counterfeit money in a scheme doomed from the start because all the bills were in the nonexistent denomination of $1 million. A Lafayette, Ind., counterfeiter did better with his bogus $100 bills, known as "Benjamins" (for Benjamin Franklin, whose likeness appears on the front). His mistake: The watermark, when held up to the light, showed Abe Lincoln's face -- apparently the result of using a $5 bill as a model. (Otherwise, said police investigator Jeff Rooze, the fakes were excellent. Police charged 22-year-old Earl H. Devine with four counts of forgery and four counts of theft.)

--Twin Falls News-Times, Oct. 8; Journal and Courier (Lafayette, Ind.), Aug. 11

BLING 1, MATERNAL INSTINCT 0 Firefighters in Stamford, Conn., had to break a car window, against the owner's wishes, to rescue her 23-month-old son, whom she had accidentally locked inside along with the key. According to police reports and a 911 tape, the kid had been sweltering for more than 20 minutes on an 88-degree July day when Susan Guita Silverstein, 42 (who was later charged with reckless endangerment), asked firefighters to wait until she went home to get a spare key so they wouldn't have to damage her Audi A4.

--Stamford Advocate, July 26

DO I LOSE MY PLACE IN LINE? As a registered sex offender in California, James Andrew Crawford was required to notify authorities if he adopted a new "domicile" for more than five days. He was arrested in May for noncompliance after he camped out for two weeks in a theater line waiting for "Star Wars: Episode III" to open.

--North County (Escondido, Calif.) Times, May 19

LAWYERS UNFAMILIAR WITH THEIR OWN CLIENT In court papers filed in 1994 but which only this year drew public attention, lawyers zealously representing the Catholic Archdiocese of Portland, Ore., offered an unusual countercharge to a child-support claim against Father Arturo Uribe: that the mother herself was negligent because she had engaged in "unprotected intercourse." The lawyers did not explain how this defense squares with Roman Catholic doctrine, which regards birth control as a sin.

--Los Angeles Times, July 24, Aug. 3

Good stuff. Head over to the original if you want more --

Happy Christmas!

Merry Christmas and Happy Holidays to everyone! I hope you're enjoying beautiful presents, delicious food (especially those Christmas cookies), and wildly gesticulating drunk uncles. But most of all, I hope you're healthy. Take care of yourself, folks, and come back Monday for more Healthy Policy! I'll be blogging through the break, (not like I've got much else to do these days considering my invalid status) so keep coming by. I'm even going to mix it up a little on the content, thus further entrenching my must-read status.

I'd also like to renew my call for introductions via email. Some great people responded to the last summons -- it appears the rest of you just need some prodding. I love knowing who's coming by, so feel free to let me in on your blog trolling tendencies: ksteadmanATgmailDOTcom. (Especially you women folk -- I haven't had a single girl email me! What's the deal ladies?)

Saving Stowers

About 2 miles from me there lies a beautiful, state of the art, impeccably landscaped building complex. It's called the Stowers Institute, and it was recently built to bring top flight medical research to Kansas City (for those of you who don't know, KC isn't really pegged for it's world-renowned medical facilities). I attended a seminar there back when I was still on my pre-med kick and doing research in lab at the medical school. The facilities were gorgeous and luxurious.

So you can imagine my anger when certain Missouri legislators proposed a ban on all stem cell research in the state and the Stowers Institute announced it might have to leave. But fear not, the polls have spoken! (and the voters will soon follow)

Earlier this week, the Republican polling firm Market Strategies released the results of a very comprehensive survey studying Missouri voters and their views on stem cell research. The poll, which was meant to shed some light on where exactly the electorate stands on the Missouri Stem Cell Research and Cures Initiative Amendment, found that an overwhelming majority support the notion of stem cell research, with close to 90 percent supporting adult-type stem cell research and nearly two-thirds backing embryonic stem cell research. Missouri Democratic Party spokesperson Jack Cardetti told Roll Call (subscription only) that the initiative could prove to be a “political minefield” in 2006 for Sen. Jim Talent, who along with Kansas Sen. Sam Brownback co-sponsored a bill that would ban a certain form of stem cell research known somatic cell nuclear transfer.

Anything that's bad for Brownback is good for me! And Jim Talent -- he's just plain evil. Point two for the advancement of science!

Do we aid in its demise?

Ezra's got a post up asking an important question:

There is a serious question here: should Democrats be fighting to strengthen the current health care system because it's better for folks in the short term? Or should they allow it to collapse, hastening the switch to a more equitable, affordable, and sustainable structure? The two are not necessarily mutually exclusive, but they may well be. So while the spectrum of options is larger than Newman and Sklar, there's a basic, legitimate point of contention here. Do you sacrifice long term gain to avoid short term hurt and allow the system to limp along indefinitely? Do you burn the village to save it? Or is there, in fact, a viable middle way?

Burning the village is a terrible horrible very bad no good idea.

The issue at base here is whether Democrats should advocate for ending the employer tax break for health benefits in favor of a program to strengthen health benefits for the poor.

What makes Democrats think that they can successfully do this? There is no way, until 2008, that this is even possible. Do backers want the Democratic candidate in '08 to have this as an initiative? How unbelievably poisonous would that be? This conversion isn't feasible, period. Even if the deduction was eliminated, there's a slim to none chance that it go toward health care for the poor. Americans around the country will say, "they have Medicaid!" and efforts to the contrary will be killed.

Further, it's unnecessary to ask if Democrats should hasten the collapse of the status quo -- Republicans are doing it for them! Consumer Directed Health Care, HSAs, High deductible health plans, all the "market oriented" fixes experts currently tout are going to be nothing but another dip in the graph (see below) in five years, followed by the inevitable rise in spending. Everything policy makers have tried before has failed -- CDHC changes aren't nearly as intense as managed care. Thinking their impact will be greater is just silly. The system is working itself to implosion already.

Now, onto the Machiavellian ethics of burning the village. Progressives should never advocate for policies that hurt large numbers of vulnerable people as a means toward a desired end. As a commentor over at Ezra's wrote:

Here's the thing:

Politics and policy are not games.

There are real people who get hurt when people in positions of power decide it has to get worse before it gets better. And, guess what? The people who get hurt the most are the poor and working poor.

There are many workable plans for universal coverage. But it will require a political fight. And doing it on the backs of the middle class is no way to build a long term progressive future in this country.

It's as simple as that. This isn't a political game about the hurricane, the war, or the deficit. This is people's health. If we're going to make major changes in the structure of health care delivery, it's our responsiblity to ensure a smooth transition. People are already hurting because of the current system. It's important to work to ease that pain in the interim, while pushing for changes to make it better for everyone.

In the meantime, Democrats should absolutely not be advocating for ending the deduction without a viable policy for major reform.

You can now feel free to get that x-ray

Via Graham, the soon-to-be doctor, why we shouldn't fear x-rays:

I think the main concern most people have about radiology is the radiation they get from a test. While high doses of radiation can be concerning for the risks of new cancers (breast, thyroid, and blood cancers come to mind), your average CT scan or x-ray is a relatively low dose of radiation (and ultrasound and MRIs don’t use radiation, they use sound and magnets, respectively). The fact is (sit down, take a deep breath), you’re getting radiation every day. Seriously! About 360 millirem per year. Do the math, and that’s about 1 mrem per day. A chest x-ray is about 2-4 days’ worth more of radiation (here’s a full list). So that’s 364 mrem per year instead of 360. While there’s no “safe” radiation dosage, as all radiation breaks up DNA and creates free radicals, everything in medicine is a risk-benefit ratio. Everything has a risk, everything has a benefit. The equivalent of getting an abdominal x-ray is like traveling 2500 miles by car (pdf) if you compare risk activities. And if you’re getting an x-ray or scan, we’re concerned you probably have something far more painful or life-threatening going on inside your body, something that’s much more likely to hurt you than the radiation will.

This is actually a quite relieving explanation. As someone who's had hundreds of x-rays in my time (yes, I know I'm soooo old), every once in awhile I shuddder when I go in for another x-ray. I worry about the amount of radiation going through my body. It's one of few areas where I obsess about the amount of toxins/various Bad Things we're exposed to in our modern age.

So thank you, Graham, for giving me a little piece of mind!

In other news, I had my first post-op appointment this morning. According to my surgeon, "I look great!". They took off the dressing (hooray for no more sponge baths) so I got the first glimpse of the damage. My leg looks remarkably straight although my knee cap seems a little askew (something that I'm assuming will be attended to during physical therapy). My incision is nice clean six inches long. I've been told it gives me character. And at this time of year a six-inch scar is nothing to complain about.

Pharma + Government Representatives = Always Higher Prices. Always

I said it before and I'll say it again: the VA is an outstanding organization that provides top-notch medical services with efficiency and cost-control unmatched in any other major sector of US health care:

Prescription drug prices under the new Medicare drug benefit are considerably higher than the prices negotiated by the Department of Veterans Affairs, according to a study by Families USA, the St. Petersburg Times reports. The study found that the median price difference for a one-year supply of the 20 drugs most commonly prescribed to seniors is 48.2%. The VA plan negotiates prescription drug prices for its five million members, while the 2003 Medicare law prohibits the government from directly negotiating with drug makers to determine prices for the program's 43 million beneficiaries.

I said it before and I'll say it again: the Medicare Part D Drug benefit is a giant sucking sound for taxpayers, whose in-bed-with-pharma(who can resist those cheerleaders, anyway?) representatives negotiated the worst deal for U.S. health care in years.

The survey also found:

A one-year supply of the osteoporosis treatment Fosamax is $493.32 under the VA plan, compared with the lowest available Medicare prescription drug plan price of $709.68;

Acid reflux medication Protonix is $253.32 under the VA plan, compared with the lowest available Medicare prescription drug plan price of $1,080;

Cholesterol-reducing medication Lipitor is $497.16 under the VA plan, compared with the lowest available Medicare prescription drug plan price of $717.84 (Nohlgren [1], St. Petersburg Times, 12/22);

According to the study, "It is very likely that beneficiaries -- and taxpayers who subsidize the Medicare drug benefit -- are paying significantly more than they would" if Medicare negotiated prices.

Why, oh why, oh why, oh why did we let this legislation pass?! Seniors deserve to know what kind of deal they got (and I'll give you hint -- it doesn't follow Wal-mart's dictum).

Is It Really Better?

Medpundit has a great post questioning the enthusiasm of FDA officials for a new cancer drug. From WaPo

We believe this represents, from a medical point of view, truly a major advance," Dr. Richard Pazdur, director of the Food and Drug Administration's Office of Oncology Drug Products, said in a conference call with reporters.

The medicine is for patients with advanced renal cell carcinoma, the most common type of kidney cancer. The FDA said that in one trial, patients taking the drug went twice as long _ a median of six months versus three months for those taking a placebo _ without the cancer progressing or the patient dying.

Wow! A major advance! But as Medpundit noticed, something doesn't quite add up:

When someone says they're "100% better," they're usually implying that they're back to normal. Cured, in other words. But, an improvement from three months to six months before your cancer spreads or kills you is hardly a cure.

Cancer medications, though essential and life-saving, are absolutely horrid to live with. I watched my grandmother waste away for five years battling ovarian cancer (a particularly nasty strain -- the ovaries secrete cancer cells all over your body). Like Medpundit says, three extra months means a lot -- but what state are people in? And is the only advance three more months of life? Though crucial time for patients and their loved ones, is the medicine just putting off the inevitable spread and death? If this represents a major advance, treatments for kidney cancer must have been in the dark ages.

Look at those knees now

The New York Times has an interesting column up by someone who recently underwent knee replacements. I've copied the accompanying graphic below because the top graphic features a brace that looks just like what I'm wearing these days (although I must admit my foot is a bit daintier than the one in the pic. But perhaps not as dainty as the one in the ice skate). The author discusses her difficulties with the procedure, namely that recovery took much longer than the surgeon suggested. Both I and other family members have struggled with disconnects between the recovery we thought we would undergo and the actual recovery we suffered through. I'm still livid with one surgeon in particular. It's essential to bug your surgeon with as many questions as possible pre-op so you have realistic expectations for recovery. There's nothing worse than feeling like you're recovering at a snail's pace when you're actually right on (the average rather than super patient) schedule.

Anyways, go take a look, it's interesting stuff for those of us with less than perfect knees.

Merci!

I just wanted to give a big happy thanks to everyone who donated to my Amazon gift card!

This means:

a) You love me, you really love me!
b) I can ensure a continuous stream of health care knowledge as some of the fund will go toward purchasing health care books
c) I promise to remain well-rounded and use some of the gift fund for non-health care stuff, like fantastic fiction or new music (recommendations eagerly accepted! I mean it -- give me some ideas in the comment thread)
d) If Santa decides to bring me coal this year, no matter -- Healthy Policy readers to the rescue!
e) Ezra is the best guest blogger ever -- not only does he provide content, he gets me stuff!

So thanks again! But the best present isn't cool books or music -- it's truly having people read and interact with my posts. (If you haven't emailed me and introduced yourself, please do -- ksteadmanATgmailDOTcom)

So thanks for taking part in my gift, but most importantly, keep coming by!

Reducing Error

Interesting news on reducing medical errors, via Modern Healthcare:

Data show that a jumbo jet's worth of patients die each day from medical errors, so it is fitting that an aviation comparison was used in a new study of one source of errors--the handoff of patients from one physician to another.

The study in the December issue of the journal Academic Medicine found that unlike among air traffic controllers and other vital safety operations, there are few systems to deal with patient handoff when one physician leaves the hospital and another takes over. The result is that the handoff is routinely botched--the result of poor communication and training and insufficient information systems--with dire implications for patients.

The solution is to teach physicians the handoff process using a model based on principles of adult learning, effective feedback and clinical experience, the study authors say. "Computerized medical records can facilitate face-to-face handoffs," he says. "Body language and other crucial factors are lost when the handoff is done over the phone and a written handoff may be difficult to read--doctors have notoriously poor penmanship--errors especially in numbers or decimal places are easy to make, and written notes are open to misinterpretation or misplacement."

I love the jumbo jet a day analogy because the gravity of medical errors is often prone to understatement. And in the post 9/11 world, extending the analogy further and comparing doctors to air traffic controllers is particularly potent.

But here's what I don't understand. Obviously EMRs can reduce errors, but if what the study authors believe is true -- that there's no substitute for a face-to-face handoff-- they can only do so much.

Along with HIT fixes, we should also be asking how can we facilitate more face to face handoffs. If my recent hospital stay is any indicator, that's no small task. Considering my doctors seemed to be on completely different schedules, and considering the pressure to be as efficient and speedy as possible, it's no wonder this task isn't always accomplished. How can we reduce those pressures, along with additional methods of reducing errors (EMRs), to prevent those 100,000 deaths? Any one of us could be included in that statistic this year. If face-to-face handoffs can't be attained, is it possible to integrate video conferencing technology?

This Time Around

As my conspicuous absence may have indicated, I’ve been a bit under the weather lately. And by under the weather I mean in the hospital for three days followed by three days of nausea, sleeping 16 hours, a Chief’s loss, and suffering the effects of prescription pain meds (and I do mean suffering – pain pills aren’t nearly as fun as they’re made out to be).

I don’t just run this blog for kicks. I don’t spend hours each day poring over news, commentary, and Health Affairs articles for class or work. It’s never been an assignment, and it’s never been about entertainment. I do this because I’m all too intimately acquainted with the health system. If you added up all the time I’ve spent in doctor’s offices or waiting rooms, it would equal at least one year, and possibly more. I know its inimitable role in improving our lives, as well as the complete insecurity accompanying the uninsured.

One thing was different about this time around: for the first time in my life, the memories of my hospital stay will be more than distant spots of cognizance (granted, they won’t be the sharpest memories in the drawer). This was my first hospital stay as an adult. From this side of 18, things couldn’t be more different.

I want to make an essential distinction: receiving treatment through an overnight stay in the hospital is a fundamentally different way of experiencing care. You know that saying “It takes a village...”? That holds true in the hospital -- considering the virtual parade of people who needed something from me, it’s no wonder staying in the hospital is so expensive. I had seven different nurses and 4 nurse techs, food delivering people, a team of orthopedic docs who would come at separate times (6 am and 6:45 am, respectively), the brace guy, the lab people, physical therapy....

For your easy reading pleasure, I’m going to make my main assessments from the recent infirmary stay in bullet form:

• Do not expect to rest in the hospital, especially post-surgery. Invariably someone will declare their presence five minutes after you nod off. This includes the physical therapy person who gleefully announces, the day after they cut open your leg and put a huge plate in, that it’s time to learn crutches and practice stairs!

• Do not expect to get any real information out of your doctor, as you will only see him/her for three minutes at 6:30 a.m. By the time they’re done, you will still be rubbing your eyes trying to figure out which health practitioner is bugging you this time.

• Morphine isn’t nearly as fun as you remember and its main effect seems to be making it impossible to pee. It is also not any stronger than oral pain meds, according to the anesthesiologist (strangely reminiscent of Alan Alda, but it could have been the morphine). This was news to me! I would have demanded to be off it ASAP if I knew that!

• Expect to remember one more thing you needed right after you send the nurse out for something else. You will then feel guilty for making her run around so much, but not as guilty when she returns and hour later with the other item.

• Plan ahead! The second you need to use the bathroom, do it! Invariably someone will come to take you to some test if you wait, and you will get stuck on the x-ray table for 45 minutes while they find someone to transport you back to your room. That also goes for your pain meds – order your next one an hour early. It will take an hour to get it, and it will feel like the longest hour ever.

More to come. I’m still healing, folks, and it will take a few days to get back to my normal blogging output. Now don’t run off and get any unnecessary treatment while I’m gone...

Well Knock Me Over With a Feather

By Ezra

I don't know when the New York Times worked up the courage to actually propose some health care solutions, but it's certainly a refreshing change. This article explaining that the health care deduction on your income taxes is an absurdly regressive measure that entrenches the perverse and inequitable elements of the system is great stuff, but watching it venture a step further and sketch out how the money could be re-channeled to create universal care is a near-revelation. I didn't know newspapers could be so constructive! And then to straight up explain that Americans will resist this solution out of self-interest...I mean, man, I need a cigarette over here.

Whew. That was hot.

By the way: Kate'll be back on the site tomorrow, so if you've not yet thrown a buck to her Amazon gift certificate (and that includes nearly all of you), now would be a good time.

Medicare Backlash

By Ezra

Looks like Medicare Part D just can't hear a kind word, even among those specifically chosen to say kind words about it:

Stephen Nohlgren writes in the St. Petersburg Times: "While President Bush was in Virginia touting his new Medicare drug plan Tuesday, delegates to the fifth White House Conference on Aging demanded it be overhauled.

"Their paths never crossed.

"Unlike his three predecessors, including his father, Bush will not attend the four-day conference. The administration is well represented there, a White House spokeswoman said.

" 'The purpose of the conference was to develop recommendations for research and action in the field of aging and present a report with their findings to the president,' said spokeswoman Jeanie Mamo. 'The president participated at an event in Springfield, Va., to educate seniors on Medicare prescription drugs and encourage them to sign up with the program.' . . .

"Bush, Republican governors and Republican members of Congress appointed most of this year's 1,200 delegates, which makes the resistance to [the drug plan] particularly striking."

Remarkably, it gets worse:

Larry Lipman and Ken Herman write in the Palm Beach Post: "Rather than embracing the Medicare drug law and Bush's call for private Social Security investment accounts, delegates at work sessions on those issues overwhelmingly rejected those positions.

"In nonbinding position statements developed at conference workshops, delegates called for scrapping the 2-year-old Medicare drug law -- which takes effect next month and relies on private insurance companies to provide benefits -- and replacing it with a government-run program similar to how Medicare covers doctor and hospital care.

"Delegates also vehemently rejected any proposal that would divert Social Security payroll taxes into private investment accounts. Such a proposal had been Bush's top domestic priority earlier this year, but has been largely abandoned since the summer."

When the White House can't rely on hand-picked conservatives to support their proposals, you know that the wheels have not only come off the train, but the resulting derailment crushed a lame duck. Don't get me wrong, Medicare Part D is a bad program, but the backlash it's engendered is really astonishing. Given the level of disgust, the electoral importance of seniors, and the paucity of congressional support for the bill, I'd be surprised to see the current conception of Part D last more than three years.

Amazoning

By Ezra

This may not be on the topic of health care, but it does dovetail nicely with the whole Amazon gift certificate thing:

But Amazon: They went from simply selling books to selling All Books in the Universe, to selling CDs and books and appliances - and razors and maybe even toothpaste and perhaps even small Asian children for adoption (Your Gold Box: Quy Loc of Cambodia. You have sixty minutes left...). It's the online megamart for those of us too lazy to go anywhere else.

And yet I find their recommendations so puzzling. I have never bought anything from Amazon that was not a CD or a book, but still they recommend appliances and electronics, like tool belts or vacuum cleaners, and every time I wonder: what is this algorithm that has me, buyer of New Pornographers and Spoon and Sufjan Stevens, pegged as someone who needs a Roomba? If I bought Brooks & Dunn and a Panasonic blender, would it suggest I buy a Dirt Devil (or better taste in music)? Is Amazon a better judge of what I need than I am?

Maybe so. I was searching for a way to connect this to health care, but aside from some clunky segue into how Amazon and its recommendation system is really the only force likely to make HSA's feasible, I got nothing. That's fine, I'm a bit wiped and health policy, frankly, didn't do a whole lot today. Now that's ace reporting: admitting that all's quiet on the western front. Oh -- and Kate's surgery went well, so she's probably in the wide, wonderful world of painkillers as we speak. All the more reason to hook her up with an awesome Amazon gift certificate. I know she's always wanted a small Cambodian child.

When Moving Lips Equal Lotsa Lies

By Ezra

Man, the Wall Street Journal's stacked debate on HSA's isn't off to the world's most illustrious start:

More than a decade of experience in South Africa, seven years of experience with the Medical Savings Account pilot program in this country, three and a half years experience with Health Reimbursement Arrangements, and two years experience with Health Savings Accounts has produced no evidence of patients skimping on needed health care.

So how's South Africa liking their flirtation with HSA's?

Private health care costs have hardly been contained. In fact, the opposite is the case. Between 1996 and 2001, the cost of specialty care increased 43 percent, and the cost of hospital care rose 65 percent. This represents a marked increase from the inflation rates for the five years prior. There have also been substantial increases in plans' administrative costs (which include profits). Meanwhile, the number of South Africans lacking health insurance--which is the bulk of the population--has continued to grow rapidly. Consumer-driven health plans have also done too little to address South Africa's most pressing health problem: HIV. Before this year, many medical schemes covered only badly needed antiretroviral treatments as part of their medical savings accounts, and they stopped providing the treatments when funds dried up. (In January, the government mandated minimum coverage for HIV.) [...]

The South African experience with consumer-driven health plans and medical savings accounts may soon be drawing to a close. In 2002, the country's Department of Health conducted an inquiry into the South African health system that, though nonbinding, has been influential and is expected to lead to change. Its conclusion: Savings accounts should be phased out of medical schemes. As its authors wrote, "The focus of health policy needs to be on risk-sharing and cost containment. None of these key health policy objectives can be achieved through medical savings accounts" (italics in original).

Ah well, I'm sure it sounded good. As for Goodman's contention that "two years experience with Health Savings Accounts has produced no evidence of patients skimping on needed health care," so far as I know, two years experience with HSA's has produced almost no evidence of any sort. However, the gold standard on this subject is the famous RAND Experiment, and skimping on necessary and unnecessary care in proportion was exactly what it found.

At times like this I like to recall Daniel Davies' business school axiom: "Good ideas do not need lots of lies told about them in order to gain public acceptance." Looks like HSAs are failing that test.

And remember: don't be a scrooge, throw a couple bucks to Kate's get well gift certificate. Otherwise, the baby jesus will cry a thousand tears.

Hiya

By Ezra

Hey folks. As you know, or at least would know if you'd been paying attention, Kate's gonna be laid out this week with a truly nasty knee surgery. That's not to say there are many kind and gentle moments under the scalpel, but she's having no fun. I promised her I'd provide content while she enjoyed the fine hospital hospitality -- but I'm going to aim for a bit more than that. During the next three days, I'm going to conduct a bit of a fundraiser over here. The way it'll work is simple: I'll keep bugging you for money, and, at the end, assuming you've donated some of it, it'll purchase a nice Amazon gift certificate to carry Kate through her recuperation. She's got three total months of recovery and at least a little while of effective immobility to look forward to -- and how much awesomer do you think those months will be if she can buy herself all manner of books, dvds, and music? And how terrific will you feel for being a part of it?

Yeah, that's right.

Pretty terrific.

So I've tacked a PayPal button below -- use it. If there's demand for an Amazon tip system, I'll start one of those accounts, too. In the meantime, I'll also put up some actual content, in addition to increasingly plaintive pleas to help the cause. Cause Kate. And c'mon, look at that face, how could you not want to help!?

Unless you're a bad person. In which case it all makes sense now. But you're not a bad person, are you?

Grand Rounds

Grand Rounds is up over at the Pipeline, featuring yours truly and a number of other highly excellent and interesting health blogs. If you're bored, expect to get entertained for awhile...

And can I just comment for a moment on the peace and brotherhood encompassed in Grand Rounds? It's wonderful that health people from all sides of the aisle can come together without quibbling and pointing fingers to engage the topic we love. Good stuff.

And now for a little history

Matthew Holt has a fabulous column with a brief history of U.S. health care:

Although shamans and faith healers have been around since the dawn of civilization, the prominence of "my son, the doctor" in American culture is relatively recent. Up until the early years of last century a visit to the doctor was statistically as likely to harm a patient as to help them, and a hospital was a place poor people went to die. Like much else that's familiar to today's cognoscenti, it was technology that made the difference, and the technologies that mattered were mostly anti-biotics and anesthesia, which enabled doctors to correct disease with drugs and defects with surgery. Following an age of development in the 1920s and 1930s, a combination of government financing (the Hill-Burton Act) and hospital and physician-organized pre-payment systems (Blue Cross and Blue Shield plans) fueled an explosion in hospital construction and health care spending. The new technologies gave them something to spend that money on.

Go read it and brush up.

Shifts in Retiree Benefits

Kaiser just released its report on the status of Retiree benefits. It's jam-packed with important and interesting stats, so here's your guide to the shape of Retiree health care, courtesy of Healthy Policy:

• More than nine in 10 (93 percent) surveyed firms that offer retiree health benefits provide coverage for both pre-65 retirees and age 65+ retirees

• The total cost of providing retiree health benefits increased by an estimated 10.3 percent, on average, for surveyed employers between 2004 and 2005.

• Nearly two-thirds of all surveyed firms (63 percent) report having a cap on their firms’ contributions to retiree health benefits in any plan offered to retirees in 2005.

• Among those employers with a cap on the largest age 65+ plan, 59 percent said they have already hit the cap and another 27 percent say they expect to hit the cap within the next 1-3 years

• The weighted average total premium (employer and retiree) for newly retiring age 65+ retirees in the largest plan is $340 per month, and the weighted average retiree contribution for new age 65+ retirees is $128 per month (including firms that do not require retiree contributions to the premium)

• Nearly three in four employers (71 percent) increased retiree contributions to premiums between 2004 and 2005. Employers also reported that they increased retiree cost sharing (34 percent), raised deductibles (24 percent) and increased retiree out-of-pocket limits (19 percent)

• Virtually all surveyed employers (99 percent) provide prescription drug coverage to age 65+ retirees.

• 79 percent of surveyed employers – representing 89 percent of age 65+ retirees in the largest plans – expect to continue to offer prescription drug coverage and accept the tax- free subsidy for their largest group of age 65+ retirees

So the key things to take away from this survey aren't surprising, with the exception that most employers will continue to offer drug coverage in the face of Part D. Similiar to the rest of the health insurance sector, costs increased 10% and employers responded by shifting costs onto employees. The average premium is standard, at $340 a month, although retirees pay a bigger portion than the average individual ($1,536 a year vs. $610 for single).

We all know getting old is expensive, and boy is it showing: 59% of retirees have already exceeded their spending cap, coupled with 27% who will follow in the next few years. Thank God for Medicare --spending caps aside, the number of firms offering health insurance is dwindling:

Between 1988 and 2005, the share of employers with 200 or more employees offering retiree health benefits declined from 66 percent to 33 percent, which is likely to increase the number of future retirees without such coverage.

Just one more reason the drug benefit with it's black donut hole is totally ridiculous. Fewer and fewer retirees will have insurance coverage through their employer, so we decide to give them a convoluted program with a huge hole in the middle. Well done.

The benefit is designed to help employers as well by giving them a 28% tax subsidy if they discourage their employees from signing up for plans:

On average, surveyed employers are estimated to receive savings of about $644 per individual retiree in 2006, with the level of savings varying according to the type of strategy pursued and the degree to which employers subsidize the current drug benefit. Those savings are significant, but when placed in the context of spending for all retiree health benefits, both medical and prescription drugs, and for pre-65 and age 65+ retirees, the savings represent a relatively modest share of the total cost.

From the retiree perspective, employer-sponsored benefits are relatively generous when compared with the standard Medicare drug benefit, suggesting it may often be in retirees’ best interests to remain in employer plans.

I'm sorry. What is the point of this legislation again? We are discouraging people from signing up for it, making it horribly complicated to do so for those who have no other coverage, and then make a big hole for people to fall into in the middle of their drug coverage (which might not even cover their pharmacy or medications in the first place). And it's still going to cost $700 billion over the next decade. I think I need to go lie down.

Cheerleading and Drugs, a Beautiful Combination

Remember the New York Times article on cheerleaders-cum-pharmaceutical reps a couple weeks back? My editors at Campus Progress decided it was worthy of my discerning pen. And thus my sixth column was born:

Considering the lax regulations surrounding doctor-pharmaceutical rep interactions, it should be no surprise that the tiny girl on top of the pyramid is now among the pharmaceutical industry’s ranks. It’s no secret that attractive people can be more persuasive than their less lovely counterparts. But do the ranks of reps really resemble the cast of Bring It On or did the article make a trend piece mountain out of a molehill?

What did I conclude? Are cheerleaders really storming the likes of Pharma, or is it just good old fashioned sensationalism?

Click over to find out.

Questions

Anyone know some good resources on dental care and insurance? My usual stash is remarkably unhelpful on this topic...

Against HSAs

Longtime readers are familiar with my skepticism towards HSAs. Fuchs and Emmanuel, in the last Health Affairs offer an excellent and succint commentary on why HSAs won't deliver:

Health savings accounts. Some incremental reform proposals have objectives other than reducing the number of uninsured people. Consumer-directed health care, subsidized by favorable tax treatment of HSAs, aims at making patients more cost-conscious, leading to usage reductions and possibly more price competition among providers. It is also said that if costs to individuals vary with use, they will have an incentive to choose healthier behavior, such as stopping cigarette smoking. Out-of-pocket payments do give patients an incentive to use less care; whether they are able to make appropriate choices is much more doubtful. The RAND Health Insurance Experiment showed that patients with a higher percentage of out-of-pocket expense use less care, but the proportion of care that experts deem "appropriate" did not vary with the extent of insurance coverage.

There are several reasons for thinking that HSAs, or large deductibles in general, would not have as favorable an effect on utilization as advocates claim. First, a large fraction of health spending is accounted for by a small proportion of patients—patients whose spending levels will be far above their deductible. Second, even for those who have not yet exceeded their deductible but expect to do so before the end of the year, any particular test, visit, or procedure will effectively be free because the patient’s total outlay (the deductible) would be the same, regardless of whether or not they get the particular service. Third, a considerable amount of care is elective with respect to timing. People who have exceeded their deductible have a great incentive to undergo in the same year all of the tests and other procedures that they are contemplating because there will be no cost to them. Finally, a deductible that might be reasonable for a high-wage worker would be unreasonable for one making much less. Thus, there will be pressure to have the deductible vary with income, and that will give rise to other problems, including increasing the administrative costs of such plans.

Great points, and one that should have been obvious to me but I never quite realized: If 20% of Americans account for 80% of spending, how much, really, can be saved? If the majority of people are spending hardly anything, and the rest would blow their deductibles regardless, net savings will be small. Why punish 80% with high deductibles ($2,000 at least for individuals) should they be unlucky enough to get sick that year when the other 20% will spend their deductibles anyway? Put that way, the whole thing is really twisted. We're making life harder for the generally healthy by charging them expensive deductibles when they're the ones using the least care. Only in American health care would this be a good idea.

If you're new to the HSA debate, I recommend my Campus Progress column summarizing the rules and controversy around HSAs.

All in a day's work...

Go read this post by Dr. Charles. It's the funniest thing I've read in awhile.

A Day to Be Thankful

Graham has an interesting post up on a woman presenting with chronic pain and no other symptoms. She's also difficult:

She immediately says, “I’m not taking any drugs. I’m sick of trying drugs. My father was a pharmacist. I can look at any drug and tell just by it’s name that it’s going to have side effects. And that it’s not going to work.” She produces a list of drugs she’s taking, including amoxicillin, a pretty standard antibiotic, for an ear infection. She says that “all these give me side effects.” “Even the amoxicillin?” I inquire. “Yes, that one just gives me terrible side effects.” I ask her what the side effects are, and she says she “can’t even describe them.” My initial instict was to press her to try to find out what her side effects are, but I let it go.

My heart goes out to her, difficult as she sounds, because there was a time I thought I was sentenced with chronic pain for the rest of my life. Which brings me to an announcement that I need to make.

I am blessed with a difficult knee that likes to flare up, give me lots of pain and not respond well to anything but staying off of it. I had a few substandard orthopedic docs tell me in the last few years that nothing could really be done and it was just the grave I'd have to lie in.

I'm not entirely sure what changed in the few years between the "nothing can be done" docs to the recent round of "you need this surgery and it will really help you" docs, but apparently I can be fixed! I'll be admitted to the hospital Wendesday morning bright and early to undergo an osteotomy of my femur (you can read all about the procedure at WebMd's page here.) So I have good news and bad news:

Good News:

According to WebMD (and my surgeon): "If the amount of correction needed to align the knee is relatively small, osteotomy is successful in stabilizing the knee and relieving pain symptoms in about 90% of cases." That means I'll be coming out of this much better than I went in. My surgeon also told me I'll be able to do pretty much anything I want post surgery barring running marathons.

Bad News:

I will be in the hospital for three days. That means tomorrow is my last blogging day, and you will have to live without my special blogging abilities until next Monday. But fear not, a special guest will help me fill the blank space, so keep coming!

Good News:

I expect to have some excellent hospital stories to entertain you upon my return, followed by surgeon stories, physical therapy stories, and crutches stories. So if you haven't been coming by my blog often, it's time to up the frequency lest you miss my fabulous medical stories.

Bad News:

I won't be able to tell you those stories until I'm out of the hospital; morphine isn't really the best writing enhancer.

So, in sum: Go read Graham's post on the woman with chronic pain, I will be gone Wednesday through Friday but a special guest will provide content, the surgery will fix my pesky knee and I will have good stories. All in all, not a bad deal.

Doing HIT Right

Matthew Holt has an interesting post up on his latest editorial on electronic medical records (EMR) and a physician's response:

My cursory assessment is that electronic records are vital in improving the healthcare delivered to patients, particularly those with chronic illnesses, over the continuum of care. But it's clear that when they're introduced to ICUs or ED, where speed is the key and care processes are not well defined, things may not be so successful. A real examination of the process absent the technology, and a massive commitment from vendors to improve the human-computer interface, is quickly needed before the movement toward CPOE and EMR is stopped by these kinds of stories. After all, it's easy for a hospitals or physician groups to decide instead to do nothing.

Matthew really sums things up perfectly. As the Children’s Hospital in Pittsburgh demonstrated, installing a CPOE is not even half the battle.

Many of us are familiar with the triumphalism surrounding HIT development and use. But one cause for concern is the apparent lack of standardization going into the implementation of EMRs. This Health Affairs article noted: "effective EMR implementation and networking could eventually save more than $81 billion annually—by improving health care efficiency and safety." While the move to adopt HIT is progressing at a snail's pace, all that extra time is just adding up to extra problems. Obviously different hospitals need different operating systems, but without standardization in something as basic as the medical record, we can kiss a good chunk of that $81 billion good-bye.

Matthew's commenter replies:

The move toward EMRs is not being led by physicians or hospitals, so our input is amazingly irrelevant. The movement is largely based on a fallacy that improved technology will lead to decreased cost, with a side bar of improved quality of health care. It is led by business interests and followed by the government - ie, the payors. Improved technology will be a huge boon for consulting firms, administrators, and other types of technician and advisors. It will absolutely not decrease costs. Only improved rationing of health care resources will do that.

This physician makes a great point in that the move toward EMRs isn't led by doctors or hospitals, but by communications people, analysts, insurance companies and health policy wonks. That's a problem. As much as physicians are proving supremely difficult to bring along on the ride, there are just too many instances of resistance and error to keep doing it that way. I've called for it before, but we have to ensure medical practitioners (not just doctors, nurses will be doing the bulk of the work) are deeply involved in the development of this software.

The one thing I don't get from this commenter is how she can say with such authority that "It will absolutely not decrease costs." What's her basis for that, given the huge mountain of research suggesting otherwise? Again, we have to ensure our HIT implementation is done right, with some standardization and ample input from practitioners, but even with stumbling along the way money will be saved. Savings are estimated in the tens of billions -- we can't afford to mess this up. And the money isn't nearly as important as the lives that will be spared from medical error and the quality of life improved thanks to better care.

Oh No You Didn't...

The New England Journal of Medicine is pissed:

Dr. Gregory D. Curfman, the journal's executive editor, sharply criticized Merck for the way it presented data from the clinical trial. The study, called Vigor, covered more than 8,000 patients and was published in the journal in November 2000, almost four years before Merck stopped selling the drug.

"They did not disclose all they knew," Dr. Curfman said. "There were serious negative consequences for the public health as a result of that." . . . In the editorial, "Expression of Concern," the journal said that the authors of the study had deleted some data about strokes and other vascular problems suffered by patients in the Vigor