Health Wonk Review, Health Care Renewal Style

Welcome to Health Care Renewal. Health Care Renewal was the product of brain-storming by some physicians and health care researchers who wondered why as health care costs inexorably rose, access decreased, and quality remained stagnant. With health care reform again looming, no one seemed to be able to explain this, much less have any solutions.

We found we all knew stories that suggested systemic problems with health care that provided some explanations, but seemed rarely to be discussed in polite conversation.

Basically, the problems arose from concentration and abuse of power. As health care organizations grew ever larger and more powerful, their governance became more unrepresentative of their constituencies, secretive and opaque, unaccountable, and unethical and amoral.

Resulting practices were marked by conflicts of interest, deception and dishonesty, intimidation and coercion, and sometimes outright corruption, bribery, fraud, and other criminal behavior.

Although many physicians knew of local examples of these issues, and some cases had been described in the local news media, they produced few echos. In particular, discussion of them in academia and the medical and health care and policy literature seemed taboo. We called this the "anechoic effect."

The mission of Health Care Renewal is to discuss these problems, end the anechoic effect, and help find solutions. We present this edition of Health Wonk Review in this spirit, and with an organizational framework derived from the discussion above. We feature submissions by many HWR regulars, but also note posts in many of the newer blogs that too are concerned with the dark side of health care.

Health Care Reform and Policy in General

On the Health Care Policy and Marketplace Review, Bob Laszewski noted the lack of differences among the health care reform proposals of the current US candidates for the presidency, suggesting "that you not cast your caucus or primary vote for a candidate based upon their health care reform plan because from 'thirty thousand feet' there isn't all that much difference" among them.

Governance

On Health Care Renewal, we have posted frequently on payments made by medical device companies to physicians and health care organizations. Of particular interest is the money that companies who make to artificial joints have been giving to the major national orthopedic associations and to some of their leaders, raising questions of whose interests these organizations really care about. (See posts here and here.) A recurring theme on Health Care Renewal is the pervasiveness of conflicts of interest that raise questions about whom health care professionals really work for, and what interests health care organizations really serve.

Practices

On the Canadian Medicine blog, Sam Solomon addressed the controversy about Canadian physicians' new practice of outsourcing their billing for uninsured services, and its implications for patient privacy.

On the Health Beat Blog, Maggie Mahar pointed out how Wall Street seems not to care about the ethics of health care corporations, "the Street doesn’t care about the ethics of what the company is doing; investors care about whether or not the company is making a profit." But, "meanwhile, both companies and individuals in our for-profit health care industry continue to engage in criminal activities."

Zagreus Ammon on the Physician Executive blog presented his "hyper realist" take on the Avandia controversy. Forgive me if I fear this "hyper realism" shades into the cynicism. For example, he asserted, "pharmaceutical companies insist on controlling and potentially suppressing clinical information about the drugs they wish to sell. This is natural and indignation is laughable." It may be natural, but it can harm patients by depriving them and their physicians of the accurate evidence they need to make decisions. It is also an ethical affront to the patients who participate in clinical research thinking they were taking part to advance science and patient care. For the latest Health Care Renewal discussion of the Avandia case, go here.

On the other hand, Dr Aubrey Blumsohn on the Scientific Misconduct Blog analyzed the shenanigans now going on in the analysis and reporting of the ENHANCE trial of ezetimibe (Zetia, and an active ingredient in Vytorin). Further commentary on this issue can be found in the Hooked: Ethics, Medicine and Pharma blog by Dr Howard Brody, and in the Medical Evidence Blog by Dr Scott Aberegg. This is just the latest of many examples of how health care corporations who "sponsor" clinical research may try to make sure the results favor their products.

A graphic example of the sorts of people some pharmaceutical companies hire to perform clinical research appears on the Clinical Psychology and Psychiatry blog. Warning, it includes how a pharma-sponsored physician researcher managed to personally give two of his patients genital herpes simplex infections.

Dr Daniel Carlat on the Carlat Psychiatry Blog reprised (here and here) his New York Times Magazine article on his brief career as a part-time paid pharmaceutical company lecturer. The article provided a vivid narrative showing the ethical challenges of one pharmaceutical company's stealth marketing practices. See also comments on Dr Carlat's article on the Health Care Organizational Ethics blog.

Cost

Dr Adam J Fein at Drug Channels examined "how the upcoming disappearance of Average Wholesale Prices (AWP) will affect Pharmacy Benefit Managers (PBMs). He argues that PBMs should not be materially impacted by a shift in the drug pricing benchmark from AWP, especially as private payors start using the new CMS benchmark called Average Manufacturer Price."

Jason Shafrin on the Health Care Economist blog analyzed the reasonableness of expecting physicians to compete on the price of procedures. He noted that this may work for very routine, low risk procedures, but may not make sense in more complex situations in which outcomes are unpredictable.

Rob Cunningham on the Health Affairs Blog reported that "Congressional Budget Office Director Peter Orszag warns that policymakers have 'misdiagnosed' the biggest problem facing both Medicare and the health economy in general by overstating the projected impact of population aging and the impending retirement of the baby boom."

On GoozNews, Merrill Goozner provided an example of how expensive procedures are hyped, while the shortcomings of the evidence supporting the procedures, and the conflicts of interest of the hypers are buried.

The next three posts related to the seeming irrationality of how government agencies pay for procedures versus "cognitive" services.

David Harlow at HealthBlawg noted that the "CMS efficiency and effectiveness machinery turns its attention (again) to diagnostic imaging, field-testing four measures which will eventually be used in denials," and "asked what about bringing the same brains and brawn to bear on the CMS approach to physician compensation generally, rather than on one piece of ancillary income?"

Henry Stern at the InsureBlog wrote "One criticism of nationalized health care is that care may be rationed. But what about paying for procedures with no health benefits at all? InsureBlog's Henry Stern has the story of how one system pays for elective hymen-replacement surgery."

Jon Coppelman at the Workers' Comp Insider blog looked "at the pending Full Parity for Mental Illnesses bill that is before Congress, and explains why it is unlikely we will see parity for occupational injuries and illnesses any time soon."

Some insights on why US government reimbursement is so seemingly irrational and inexplicable come from this post on DB's Medical Rants. The anonymous DB reminds us that all US Medicare physician reimbursement is heavily influenced by a secretive AMA committee called the RBRVS Update Committee (RUC), whose membership is not public, but seems to be dominated by proceduralist physicians. Similarly, James Gaulte on the Retired Doc's Thoughts blog explained how the RUC undermined the rationale for setting up the RBRVS (Resource Based Relative Value System) in the first place, to more equitably reimburse primary care and "cognitive" services.

On the Covert Rationing Blog, DrRich wondered if a lawsuit trying to void Medicare's irrational physician reimbursement could succeed.

On the other hand, David Williams at the Health Business Blog addressed how the US government funds, or does not fund, small health care businesses. He interviewed "BIO's Alan Eisenberg re: SBIR grant eligibility for majority-VC [venture capital] backed companies, [letting] ... Eisenberg tell BIO's side of the story."

One post addressed the weirdness that seems to infect normal people when they try to write about health care costs. On the Health Beat Blog, Maggie Mahar critiqued the "muddle" that a New York Times editorial produced when it addressed health care costs, weaving "truth and error together in such a way that it would take a knitting needle to separate the two." and finally collapsing "into a confusion of contradictory clichés." Unfortunately, the same could be said about a lot that is written about health care policy, particularly the cost side, (but not by our HWR bloggers).

Quality

Loraine Lawson on the Good Ideas That Work blog asked, "Want to know how to curtail the spread of AIDS? Ask Brazil, where, in the early 1990s, health authorities feared the epidemic could 'grow out of control' (whatever that means). According to Reuters, new AIDS cases in Brazil fell to 17.5 per 100,000 people, which is down considerably from the 22.2 per 100,000 recorded in 2002."

Access

Ian Walsh at the Agonist blog observed that problems with health care access may arise because those who make health care policy, for example, the US Congress, have a special deal on health coverage that mean they do not have to struggle with the problems ordinary citizens face, "the fact that they live in a privileged bubble and that the reason they don't even try to fix the problems of ordinary Americans is because they don't share them."

On the Managed Care Matters blog, Joe Paduda examined how US universal coverage plans could deal with illegal immigrants, but noted that meanwhile, Mexico may come up with a universal coverage system before the US does.

Louise Norris on the Colorado Health Insurance Insider blog discussed obstacles to mandatory health insurance, noting the need to trim costs, starting with amazingly well paid hospital and managed care CEOs.

Anthony Wright on the Health Access WeBlog reviewed "two articles on the SCHIP fight, California’s pending decision as a result to disenroll kids from coverage, and why the problem is both worse than we think (violating 10 years of outreach and trust) and better (there’s a certain political resolution)."

Thanks again for visiting Health Care Renewal and perusing the Health Wonk Review. The Health Wonk Review web-site is here. Also, see our side-bar for a nearly complete listing of previous Health Wonk Review editions.