The Health Care Blog

QUALITY/POLICY: P4P get official in Businessweek, no less

So in a remarkable bit of futurism, only 8 years after Greg Schmid invented the concept at IFTF (well, we end up calling it performance-based reimbursement, but it's the same thing as P4P), Businessweek has noticed and Pay for Performance has gone mainstream.

I'm still looking for someone to find an earlier citation of an equivalent term or concept--I still can't believe that we allowed a non-healthcare economist to invent the term!  And with reference to the Gianfranco post from yesterday.... Greg came into work every day for 5 years and always said to me "How come they named the football team you support after the President's daughter?"

OFF TOPIC: Zola retires

The greatest Chelsea player ever, and one of greatest gentleman in world football, retired yesterday. Thanks, Gianfranco.

PHARMA/POLICY: More on Plan B and its relationship to the overall chaos at the FDA

A little more about my FDA article from Monday....

Prospect/Nation journalist Ayelish McGarvey, who wrote the article about David Hager, and knows way more about Plan B than I'd ever want to, says that I (and by implication Robert Steeves who's earlier article on Plan B I lifted for THCB) don't actually understand what's really going on with Plan B's non-approval. She tells the real story in a long comment to my piece over at Ezra's blog.

Essentially Barr's first application to make Plan B available OTC was turned down. The delay in approval, over which the three Dem senators are holding up Crawford's nomination is for a second application in which Barr Labs asked to put Plan B behind the counter for women over 16 years old and by prescription only for those under 16. FDA hasn't approved drugs in that manner before, and its lawyers won't sign off. To know more we need to wait till McGarvey's article comes out (next week), but it's clear that in her view, Steven Galson, the director of the Center for Drug Evaluation and the surprise signatory to the original non-approval (the one that turned over the 23-4 scientific vote in favor of approval) acted more or less independently from Crawford. It's certain that he went against the staff scientists advice. This is what it says on the FDA page about Plan B:

12. Dr. Steven Galson signed the letter FDA sent to the sponsor. Does Dr. Galson usually sign such letters? Why did Dr. Galson sign the letter?

No, Dr. Galson does not usually sign regulatory action letters. However, his opinion of the adequacy of the data in young adolescents differed from that of the review staff. He believes that additional data are needed and for that reason he made the decision to take final action within the Office of the Center Director.

And the differences between the political leadership of the bureaucracy and the staff are huge. Meanwhile there is a pretty good article which I missed at the time in the NEJM on what happened, and another blog, The CarpetBagger Report, picks up the story from what Jon Cohn wrote in TNR.

On the other hand, I really only wanted to make two points about the FDA.

First, there are fundamentalist loons with an agenda inside FDA (i.e. whoever it was inside FDA who asked Hager to provide a dissenting opinion), or at least those who want to air the fundamentalist loon's opinions. I can never tell if its the fundamentalist loons using the cynical rightwingers or the other way around, but their views are clearly being heard and acted upon.

Secondly, forgetting Plan B -- which in the grand scheme of things is just another story of how screwed up sex education and reproductive health in this country have become -- the issue of whether FDA can be trusted on pharma safety overall is still a complete mess. That cannot change unless we get a total change in the current regime at FDA including Crawford, Galson and anyone else favoring either fundamentalist loons or the short term interests of big pharma over full disclosure about drug safety. I know that Ted Kennedy (and by Ayelish's implication Sens Clinton and Murray too) have given up on trying to fix that, but someone needs to be reminding the American public about it!

And, for the nth time, full disclosure about drug safety may lead to people taking drugs that could be considered dangerous.  Some people might want to take a Cox-2 and trade off pain relief for a higher chance of heart disease.  But the key is that they need to be sure that the FDA is making all the information available -- and that's where it's fallen down on the job and lost the public's trust. And in the end it's better for big pharma to be in a market where the public trusts what the government says about their products.

On another topic, talking of what pharma says about its products, the Washington Legal Foundation, which got DTC ads on TV in the first place, is causing a little more fuss in that arena.

POLICY/INTERNATIONAL: The Weekly Standard on moron support

In an article called Socialized Medicine on Life Support, there is just yet more rubbish from a libertarian doctor form a libertarian "think-tank" writing in a conservative weekly. For chrisssakes, Canada doesn't even have "Socialized Medicine" -- defined as the physicians providing the care working for the state.  That would be Cuba, Sweden or even the UK.  Canada has single payer....In American terms Medicare is single payer, the VA is socialized medicine...

It's not even worth refuting the rubbish they write, but just once it would be nice if the sources they quote actually had done some, say, real research.

And as for the hackneyed old arguments; "Canadians flooding the US looking for care". Rubbish. "Opinion polls show Canadians think their health care is in crisis" -- not compared to the US (read down to "System Satisfaction"), and "long waits for care everywhere but the US" -- again just BS.

But the point is that these guys don't need to deal with the truth or even fake real research.  Spreading FUD about anything that's not the US status quo is all that's needed.

INDUSTRY: Scrushy verdict is in--He walks

So after about 15 years of deliberation, the biggest fraud in the history of health care is coming to its zenith. The news is that the jury has reached a verdict in Scrushy trial. Now we'll see if all that showing up at black churches and sponsoring Christian boy bands was worth it....

My guess is that in the Michael Jackson tradition he walks, but in my book the crook who blames his underlings and then claims that God forgives him is the lowest kind.

Check back soon for the verdict....

And of course he walks. Not guilty on all charges. Every CFO and person who works there said that he was fully in charge of orchestrating the whole fraud, but up to 200 local preachers appeared on Scrushy's evangelistic radio show on Alabama cable and said he was innocent. So who would you trust.  A bunch of admitted crooks or emissaries from God?

The amusing thing is that he'll now try to get control back of HealthSouth. Listening to Jim Cramer on CNBC has been quite amusing...Cramer is not too impressed with the wisdom of the Alabama jury.

Now he's live on TV giving all the thanks for God, thanking all the pastors and ministers, and everyone who helped get him off.  On CNBC the squawkbox wag said "How about a foursome at the Alabama golf club--Scrushy, OJ, Robert Blake and Jacko?".  His other good line was "Lucky the charge wasn't 'Poor interviewing of CFOs" as 5 out of 5 managed to put one over on him..."

POLICY/QUALITY: The Nursing Shortage -- It's real

Over at Code: the WebSocket Alwin has a really great article about the nursing shortage called A hard rain is gonna fall. I think he's right and that after we've emptied every third world nation of their meagre nursing supply, we'll realize that we have do something about it here. And in my view that means training fewer doctors and more nurses instead.

PHARMA/POLICY/POLITICS: The FDA remains in tatters

It's time to dip into the murky waters of the FDA once more. This is a classic tale of politics intruding into an agency that should have science as its prime motivator. Here's the story summarized so far.

The FDA has barely had a full time official commissioner since the start of the Bush Administration. Mark McClellan was officially head for a brief while in 2003, but he barely had time to look embarrassed on 60 Minutes when asked why Canadian drugs weren't safe enough for Americans before he nipped off to the rather more rarefied atmosphere of CMS -- where he's much better suited.

Meanwhile before, after (and basically during) McClellan's time at FDA, the acting commissioner has been Lester Crawford. Some cynics have noticed that there are a few clouds over Crawford. He was involved in some pretty close to the wind activities when he was in charge of Food Safety (ironically this weekend, there's more suspicion about the Administration covering up a second case of Mad Cow).  But more recently there's been much fuss over both his personal affairs (i.e. was he or wasn't he abusing his power to forward the career of a female colleague with whom he was having a close relationship) and, much more importantly, about his being behind the non-approval of Barr Labs' Plan B emergency contraceptive.

Robert Steeves has written convincingly on Why Plan B went down.  Essentially Crawford overruled a scientific committee which voted overwhelmingly that Plan B (an emergency morning-after contraceptive) was safe and effective.  So it won't go on the market. Of course, any time you hear anything to do with "safety" in reproductive health care in this country, your ears should prick up. There are allegations that information was withheld from the Senate Panel investigating this. Whether that's true or not, David Hager the physician who apparently has Crawford's ear and was a one of the few dissenters on the panel, appears to be a certifiable loon. Yup, he attributes all his research skills and influence to God and is not shy about telling the world about it.  However, his ex-wife is not shy about telling the rest of the world about Hager's at the least inhumane and at most criminal treatment of her -- including paying her (at first) and then forcing her into types of sex that many on the Christian right probably think of as against God's law and should be banned (although they all probably indulge in private...OK that's my last direct slam on the Fundamentalists in this piece).

At any rate, it's good to know that the future of contraception in this country is in such stable and rational hands. And overall of course the whole thing is a payback from Crawford to the Christian right for supporting his appointment. 

As a result, three Democrats on the panel are going to hold up Senate confirmation of his nomination even though it got out of committee -- even with Ted Kennedy supporting him. (Kennedy says that FDA needs a leader of some kind to remove uncertainty). The real joke is that one of those delaying his vote is an even more extreme member of the Christian right, Sen. Tom Coburn of Oklahoma (ironically like Hager another ObGYN obsessed with sex, although in his case it's rampant schoolgirl lesbianism) who thinks that the FDA should be printing warning labels on condoms because they aren't effective enough preventing disease (and of course Coburn probably thinks that people shouldn't be having sex anyway).

This might all be fun and games in an inside baseball kind of way if the issues at hand weren't so damn important. Since the Vioxx scandal there is no trust of anything the FDA says about drug safety, and it's fairly clear that the FDA leadership at least has basically been in PhRMA's pocket. We're now even getting whiff of a bigger scandal about the contentious link between mercury and autism. I won't even pretend to look at the science behind that, but it's safe to say that the Robert Kennedy article that has reignited this fuss wouldn't have had nearly so much press if the FDA commanded more respect, and if the allegations that it covered up studies on behalf of the pharma industry -- as essentially it did in the cases of Vioxx and Celebrex -- weren't so believable.

The final piece of the puzzle rest with now famed FDA whistleblower David Graham. With maverick Republican Sen. Chuck Grassley in his corner, he is taking aim at the newly appointed FDA safety panel. Essentially, instead of creating an external review board with the power to pull drugs from the market, the FDA has created an internal panel to which insiders like Crawford control all the appointments. FDA needs to be seen to be scientific and neutral, but that's not happening. For example, the advisory panel that voted to continue sales of Celebrex and narrowly voted to allow Vioxx to return to market was shown to be filled with scientists with drug company ties, and that when they were excluded the tallied votes would have been very different. This may be what big pharma thinks it wants, but it's not what is good for the country or for that matter for the future of big pharma. We need an FDA that is beyond reproach or politics.

Instead we have a series of government agencies, with the FDA being a prime example, where whistleblowers are needed to maintain standards of honesty and dignity; something our Dear Leader said he was going to bring back to the White House (ha, ha). And the whistleblowers are being treated pretty badly, even if they do have the protection of an influential Senator.  (If you want more look at this article and editorial from PLoS about the treatment of whistleblowers)

Given that there are other Presidential appointments in deep trouble, and that a Supreme Court fight is about to start that will get nasty very quickly, one cynic has suggested to me that Crawford will be confirmed without a vote as a recess appointment. In any event, the politicization of every government agency has now produced a situation where the politicians, the bureaucrats and the industry are conspiring against the public. This is bad for business, bad for health care, and bad for America.

TECH: Conversation with Girish Kumar, eClinicalWorks

I wrote a brief editorial in THCB and also on FierceHealthcare last week, suggesting that the problem with IT in the US wasn't so much a lack of interoperability as it was a lack of use of IT in the clinical workspace by physicians in small practices. My editorial was in part inspired by a comment emailed onto me from Girish Kumar, who's President of eClinicalWorks--an EMR vendor aiming at that market. Given that I'm doing some work on the use of ePrescribing by doctors in that market anyway, I thought I'd imitate MrHISTalk and do a CEO interview to go down a layer or two about how that small practice segment of the market is playing out. So here's my take on my discussion with Girish.

 

eClincial Works is based in Westborough Mass , and it's a private company with no debt and no investors and no plans to go public -- working in a similar philosophy to Meditech just down the road. Currently it has around 150 employees with some $20-25m in software revenues on an annualized basis. They are doubling in size each year with 1500+ customers representing 3300 providers (meaning nurse practitioners and doctors). Their business is focused on the small end of the market, which they define as practices with 1-15 physicians, although they have started going into mid (15- 50) and large (50 +) practices. And a couple of even bigger practices have signed on recently, although that's not been their prime market.

What about the market in general?

Girish believes that EMR adoption in health care is a long term process -- and that realistically we are still 5-7 years away from peak adoption rates and some time after that from total penetration. He was (he says somewhat mis)-quoted last week as suggesting that government help was needed to get that market to take off. He does think that the conversation emanating from Washington is creating a catalyst which is helping physicians move towards automating their practices. But this is a numbers problem. While there are only a few thousand hospitals and big practices, there are over 150,000 small practices. Their EMR adoption is low in percentage terms but quite a few have EMRs which makes a large total number. Girish says that as eClinicalWorks continues to see more and more business every quarter, that tells him that the market is moving forward rather than backwards or sideways. But, and this is the key issue, the numbers of doctors needing to make that move are so large that unless the government puts in place bigger incentives the market won't go from 30% adoption to 80% without a catalyst any time soon.

Is there a distinct set of players for different practice size?

For practices with 50 + doctors there are a now a more or less dominant set of EMR vendors, such as NextGen, Epic, Allscripts & GE Centricity (Logician). When you go to the below 50 doctor market, it's coming down to 6-8 companies too, but not the same as the larger ones. For example, Epic doesn't sell into that market. There are many smaller vendors who used to be able to be much cheaper than the better known companies, but the challenge for those companies is that original price point of $15-20,000 per physician is now falling. So the difference between the small vendor and bigger, better-known players has come down. For example eClincalworks' EMR is $7500 a seat (you need to add $2500 more for the practice management module).

This is being accompanied by some level of market confidence in the vendors. Girish claims that others are telling him that eClinicalWorks is becoming a brand name for EMR. In addition the vast majority of doctors who buy their EMR product are also picking up the practice management application, and are starting to replace the Medical Managers of the world. As in many other parts of the health care IT arena, the value of the pre-integrated product can exceed the reason for keeping a legacy practice management system, and he expects to see that trend continue. Incidentally, some of his competitors, don't share that view--Allscripts for instance doesn't have a practice management module and integrates with those legacy systems. But clearly if physician organizations can recognize a distinct set of vendors who will be around for a while, then it will help the market.

So what should the government do?

In Girish's view government is recommending the standards for building the highway, (interoperability and RHIOs). There's no question that you need that for nodes (or in his analogy, cars) to be able to able to connect with each other. But we need to focus on the nodes, and we have to build the on-ramp and off-ramp to the highway. The government needs to incentivize both the infrastructure creation and incentivize the plug-in at the doctor's office. He's not critiquing building the highway but we must realize that we need the cars too.

What should that look like at the node level?

The government should come up with a subsidy either via Medicare or a pay for performance package directly related to IT adoption. Then the government should mandate that vendors implement interoperability standards at no additional cost -- customers shouldn't be burdened with the extra costs of interoperability. We need to build an incentive to vendors to do that and that incentive for vendors should be a growing market. In other words, create a market so that the vendors make more money but force them to make interoperability part of the products features. In one example Girish cited a vendor who wanted $60K to integrate inpatient and outpatient information together for single practice. That's not acceptable to him and the path to interoperability ought to be built into vendors' standard product roadmaps.

Having said that, there is only a small demand from doctors for seeing the inpatient chart in the outpatient environment, although that varies by specialty. For example, no dermatologist cares, but an ObGyn or cardiology practice might care. The big deal in terms of interoperability is access to lab results. However, overall adoption will be easier if physicians know that the products they buy are interoperable and that they are both able to get information from other systems and able to walk with their data if they don’t like the system they have.

So why should the government subsidize the EMR?

Putting aside the fact that the government subsidizes lots of parts of the health care system already, I pushed him a little on the idea of subsidies. After all if adopting technology gives the physician efficiency (and several vendors show that in their studies) and it's saving them money, why should there be an incentive from the taxpayer? Girish felt that the improvement in care EMRs would create would save Medicare and the government money in terms or reduced hospital admission, better drug compliance, etc -- so in his view it would be an investment. But he was happy enough with a proposal that any subsidy should be budget neutral overall for physicians, but that Medicare or the government would essentially be paying them to adopt the EMR while they were paying them less for other activities in their practice.

While I agree and I think that the P4P movement is pushing this way, I can imagine the AMA might not agree quite so readily! Still, I'm with Girish in believing that the adoption of EMR tools in small practices is the most crucial aspect of IT in health care, and it’s good to hear that there is some activity in that arena. And that at least one vendor is talking a good game about how that market can be grown at benefit to all of us.

POLICY: Why health care costs so much

This one is the cross-post from Ezra's blog yesterday.  I was going to do something different last night, but the wind was right and so I went paragliding instead! And it was great! I will have more on the FDA later today or tomorrow

Health Affairs (the essential peer reviewed health policy journal) has an article from the very well respected Center for Studying Health System Change (HSC) which announces that the decrease in the increase of health spending has stalled (here's the slightly more digestible press release). No kidding, the press release starts off with this line. See if you can get the gobbledygook here:

"The reprieve from faster-growing health care costs stalled in 2004 as costs per privately insured American grew 8.2 percent"

The good news is that nominal GDP growth  (real growth plus inflation) was 5.2% in 2004, so health care costs (the 8.2%) were less than double that. So in the bizzaro world of American health care, it's still something of a success when health care is expanding only are only a little under double the rate of the rest of the economy or less than three times the inflation rate. That's why health care takes up 15% of the economy now when it was around 5% in 1970.

But the two key questions are a) do we have to spend so much more? and b) what are we getting for the money?

The short answer to a) is no, we don't have to spend so much.  Most other countries spend between 6% and 10% of their GDPs on health care, and some, such as Canada and Japan in the 1990s, actually reduced the share of GDP they spent on health care.  The more complex answer to a) depends on what you think we ought to be spending our money on.  Back in the time of Vietnam and the Cold War the US spent nearly 10% of GDP on "defense".  Now we spend money on frappuchinos and viewing pictures of Paris Hilton on-line. These are all political choices, and it's clear that Americans view medical care as to some extent a luxury good that they are happy to spend money on. In her book Medicine and Culture the late Lynn Payer described the difference between the British stiff-upper lip, the French consternation about balance in the liver, and the American desire to operate on any patient who'd lie still for a moment, and she ascribed most of the difference in medical practice, and thus costs, to culture. More recently Uwe Reinhardt has shown that it's not just culture but also prices -- we pay our health care workers and supplier more than foreigners do and that's a big factor in our overall larger costs.

The other factor that allows us to spend so much more is that there is neither a competent market mechanism that stops us spending too much, nor a central budget authority doing so. Market mechanisms work in one of two ways, either on average we just can't consume more (i.e. pictures of Paris Hilton) or we can't afford to all consume as much as we might possibly want (i.e. we can't all afford Prada dog-caddying purses or whatever Paris carries her dog around in). In health care our ability to consume is essentially limitless, especially if we're sick, and usually some other sucker is paying the tab. So we are dependent either on the producers of care to say "that's enough" (which is the British stiff upper lip approach which results in what Americans call rationing and Brits call compassionate care for the sick and elderly), or on the sucker that's paying the tab to cry "Uncle!". Briefly (and this is a much more complex subject), because of our diffuse system of third party payment, none of the said suckers have either had the ability or the will to really reduce payment. And the producers here have always known that putting up their costs will result in someone ponying up. Even though as the prices go up more people get excluded out of the system on the margins, those who can stay in it will more than make up the financial difference. So costs go up, as we do more things with more technology at a higher price. And because not everyone is in the system, and there's not one universal pot of money or line-item budget, or no effective consumer pricing mechanism (and there can't be for reasons that I wont go into here), no one is there to cry "Uncle!". Of course in other countries that's usually the job of the other cabinet ministers who say things like, hey if you put all the taxes towards health care there's nothing left for education, roads, invading Iraq or whatever. When Congress votes on a new healthcare bill no-one seems to care too much about that bottom line, as the Medicare Modernization Act cost fiasco proves. Note that this is not how Walmart governs relations with its suppliers.

The second question is harder to answer. In some ways it's easy to say that we don't do as well as other countries on several outcomes measures and that we're not getting our money's worth.  On the other hand several of the things that used to kill people are now relatively easily surmountable -- at a cost.  And then there's the paying for comfort issue.  It used to be that if you had real heart trouble, you needed to have your chest cracked and have a full CABG.  No fun.  Now getting a stent put in is a relatively painless procedure that they don't even put you to sleep for. Does that lower the bar on the decision to do invasive cardiology? Indeed. Does it cost more for the payer per individual? Probably, as in the end many of those stent patients need a by-pass anyway. Does it cost the payers and society more overall? You betcha. And the parking lots outside the cardiologist suites are filled with physicians' Porsches as are those outside the executive offices at J&J and BSC.

Is that a good or a bad thing?  Complex. In aggregate the cheapest thing is to let the heart (and therefore patient) go when it's time, but we're never going to do that. So should we restrict procedures to only those in real trouble, and only give them a CABG?  Fine if you say so, but let me ask you two questions. What do you define as real trouble?  And would you rather have a stent put in while you lie there listening to Lite jazz, or have your chest cracked?

And that uncertainty is what drives our system and drives that cost barometer up.

BLOGS: Guesting

I'm guesting over at young UCLA punk Ezra Klein's very interesting political site this week so go there to take a look at this piece I wrote on why health care costs so much.

HEALTH PLANS: The Gadfly seems to have caused Kaiser real trouble

So the Gadfly has really had an effect, and in some ways so has THCB. But I'm not sure it's a good one. Yesterday for the breach of patient confidentiality that was fairly exhaustively documented on THCB and elsewhere, the California Department of Managed Healthcare (DMHC) fined Kaiser $200,000.

Just to remind you, some contractor left some database schemas of Kaiser's Health Connect project on an open web site some time between 2002 and 2004. Somewhere in those charts, which I looked at (not knowing what was in them) were patient records for 150 real live patients (although I never saw one and the Gadfly said that she only ever saw three and never knew they were real). The Gadfly linked to the site from her website, and after she wrote to me, I put it in a story here last August. Within a few days, that website had been taken down, and I assumed that that was that.

But apparently not. The Gadfly, who was involved in a nasty if unrelated dispute about her firing, had mirrored and copied the site to prove (at least to her satisfaction) that Kaiser was doing something wrong. Kaiser apparently is being fined for not reporting its breach of confidentiality. "DMHC officials were concerned that Kaiser allowed the site to languish on the Web in an accessible format and did not act to remove it until its existence was brought to the attention of federal civil rights authorities in January 2005. In addition, Kaiser authorities chose not to inform state regulators until after the site had been reported to the media in March. However, Kaiser has since informed all of the approximately 150 members who may have been affected." So playing out the time-line, Kaiser knew (we can assume) in August 2004, started going after the Gadfly in March 2005 when the story broke in the SJ Mercury News, but apparently had been told by the Civil Rights Commission in January that there its data had been (or still was) online, but didn't inform the DMHC until March.

However, given that they had taken down the offending site the previous August, really Kaiser is being punished for not informing DMHC when it knew, rather than keeping it quiet and pretending (or at least insinuating pretty heavily) that it was the Gadfly who'd allowed public access to the site. But then again the Gadfly was allowing access to the data from August 2004 until March 2005, although it was a mirror of the site that had been up for over two years.

In some ways there is some karmic justice to all this. Kaiser didn't treat the Gadfly at all well as an employee. She went after them rather too aggressively, even if she didn't know that she was showing real patient data. Kaiser in turn responded in a more than proportionally aggressive response, and never tried to work it out with the Gadly to see if some reasonable accomodation to her problems could be reached. And they failed to do the CYA necessary to stop themselves getting in trouble with DMHC. But if $200,000 is a fair fine, then it's more than $1200 per person, and probably more than a few thousand dollars per actual viewing by anyone on the web. So to my mind that's a more than proportional punishment.  And I'm not sure that it's not just DMHC grandstanding--I mean I know it was against the law, and Kaiser was slow, but I can't see that that much harm was done to any of those patients.

Now Kaiser is a very wealthy organization and had a very good year last year ($481m profit in Q1 2005 alone), so $200,000 is not exactly that much to it. But on the other hand, it's real money that could be used to provide health care to many needy people, and I suspect that had just a little been spent on better health insurance for the Gadfly, all of this could have been avoided. Of course the DMHC can now try to go after the Gadfly, but it appears that HIPAA privacy requirements do not apply to individuals.

So the lesson for health care organizations is mind your data and mind your employees, and treat both with common sense.

POLICY/INTERNATIONAL: More rubbish being talked about single payer and Canada by major newspaper columnist

I had hoped that when the Boston Globe gave Jeff Jacoby a chance to rant about Canada and single payer, and THCB was able to call bullshit, that I wouldn't have to repeat myself quite so soon. But to no avail. The Chicago Tribune gives a columnist called Steve Chapman, who incredibly enough worked for the liberal  New Republic (although aside of that has a long list of writing for libertarian and conservative newspapers), a chance to spread way more disinformation.

It's good to know that a serious newspaper can allow a leading columnist to write about Canadian health care using numbers about the length of Canadian waiting lists from hopelessly biased organizations like Fraser and Cato, but ignore the official statistics which indicate that Fraser is wrong on waiting lists by a factor of 4. And for that matter the average waiting lists quoted by Fraser of around 4 months for elective surgery aren't that bad--yet somehow Chapman starts talking about two year waiting list because one orthopedic surgeon said so.

Chapman then goes on to cherry-pick different outcomes on cancer to show that American care is better. Of course he doesn't bother looking at overall care in different countries. This article in Health Affairs did just that (and is one in a series). The result, as again commented on in THCB, is that overall there is no real advantage to being in America. We do worse on somethings and better on others, but the suggestion by the Canada bashers that we get what we pay for is well off-base. And we clearly pay a lot more than anyone else and the share of those costs borne directly by poorer Americans is much, much greater than that borne by poor Canadians (or poorer people in other nations).

And if you look at the Health Affairs study a little more carefully you come to the authors' conclusions.  Remember this is a real academic peer reviewed study, not some rubbish that Fraser Institute made up to suit its political agenda.  Here are the conclusions:

Across multiple dimensions of care, the United States stands out for its relatively poor performance. With the exception of preventive measures, the U.S. primary care system ranked either last or significantly lower than the leaders on almost all dimensions of patient-centered care: access, coordination, and physician-patient experiences. These findings stand in stark contrast to U.S. spending rates that outstrip those of the rest of the world. The performance in other countries indicates that it is possible to do better.

There's plenty wrong with Canadian health care--something I looked at in depth in my "Oh Canada" piece. I'm also pretty sure that it's not a good model for America, whereas Germany, Holland, France or Japan might well be.  But I really wish that if right-wing know-nothing columnists are going to write about this subject, that they'd either learn something about it themselves, or try to abstain from feeding at the research trough of totally biased organizations like Cato and Fraser. I suspect though that I'll be wishing in vain for a while, but shouldn't the Chicago Tribune hold itself to a higher standard?

INTERNATIONAL: The Future of Europe, Seen from a Sickbed

Timothy Garton Ash is a veteran British journalist, sort of from the Blairite "Third Way" school. He has lectured Bush on foreign policy and has been an influential writer about the collapse of communism in Eastern Europe. So his thoughts about how the health service in the UK is a microcosm of the future of Europe, which is called The Future of Europe, Seen from a Sickbed, is a great read.

It's also very relevant in the US, where an aging white population is going to have proportionately more Hispanic youngsters looking after it in the coming decades.

HEALTH PLANS: Looks like Empire has caved

So judging from the comments in the post on this subject below, it looks like Empire BCBS has decided that the headache of not paying for the young teenager's surgery exceeds that of appearing on CNN in a negative light. Very understandable, and something that more health plans need to consider, especially when they are asking for more than 10% rate increases for the 5th year in a row.

TECH: Interoperability/schminteroperability

This week the Clinton/Frist (or should it be Frist/Clinton) legislation got on breakfast time TV, and Brailer's office announced that it was going to be starting the first few pilots towards interoperability with some $60m available. A more ambitious $4bn bill was introduced too, although that won't go anywhere unless someone adds the words "Terror" or "Iraq" to the title. But while all the fuss is about interoperability of data transfer, there is a whole set of players who need data to become electronic before it can be made "interoperable". While the larger medical groups and hospitals are rapidly getting on the EMR adoption curve, it's a much slower process among the small practices that account for 75% of America's doctors and patients -- most of their information is stuck in paper. Other countries solved this problem the old fashioned way -- the government paid for doctors to get EMRs in their offices.  Before we get too worked up about interoperability and RHIOs, a bigger national push to get smaller practices using clinical information technology might be a better idea.

POLICY: Now let's remember a few basic things about Medicare, single payer, vouchers et al, with brief UPDATE

Well either the doppelgangers are firing off or a few people have been reading this blog or the Jungian collective unconscious is working. In any event several of the issues about single payer versus vouchers that have been raised here have been echoed elsewhere.  First Fuch's co-author Zeke Emmanuel in a guest spot over at Washington Monthly in response to Kevin Drum (the host there) spends some time explaining how insurance organizations (plan sponsors, an intermediary layer, call it what you will) could actually provide some innovation and be allowed to compete over that, rather than risk selection.

May be so, but there are two obvious points. First, there's no reason why competition amongst that intermediary layer need not be controlled by a single payer system -- something like that is starting out in the UK now.  My major point is that a quick Medicare-for-all legislative rush which puts us in one big risk pool is much more politically likely than an attempt to create a formula that gets us to perfect risk adjustment which Congress will pick to death while it's legislated.  Second, Emmanuel reckons that we won't get to single payer without a national crisis (and I agree) but then he thinks that the voucher system is palatable enough to somehow sneak past the special interests in the absence of said crisis. I don't think so. Significant universal insurance reform will be so difficult to do that it'll need a national crisis.  But then I'd call, say, 80m uninsured Americans a national crisis -- or at least one that may show up politically if enough of the uninsured are male Republicans in the south --and we may well get there if current cost trends continue.

Zeke also reminds us that Medicare isn't such a great program either, and I completely agree. Medicare is basically a welfare program for hospitals and providers, and soon to become one for drug companies too. It's the fact that it doubles as a way to stop old people from being unable to afford hospital care and thus from dying in the streets that gives it such popularity.  But that income protection for seniors part of it can be preserved while making the overall program better. First off, the amount of money paid to those provider organizations can be reduced (and will be), but they need to improve their productivity and stop delivering "flat of the curve" medicine (i.e. more money with no comparable output). Some hints in this direction include implementing some of the lessons from the Dartmouth crowd's work on overuse of resources in ICUs. The other part about Medicare is that it can be used as a force for good and to foster innovation. With all its warts that's what P4P is all about, and I don't see why Medicare is worse at doing that than private health insurers, which anyway tend to follow its lead.

Finally, I'd like to remind all parties that the gulf between the universal insurance crowd and the single payer crowd isn't so big, as they both have everyone covered and everyone in a single big risk pool (called America). And with some variations, the Europeans show us that multi "intermediary" systems such as the ones in the Netherlands, Germany and Switzerland can be very effective.

UPDATE: Jonathan Cohn, who seems to be giving it away over at TMPCafe these days instead of selling it at TNR, has some pretty sensible points to make about the eventual similarity between universal insurance and single payer.  He doesn't quite get to my logical conclusion -- which is that we get to some type of government-funded quasi-competitive regulated market via an extension of Medicare's single payer model -- but I think he'll be there eventually.  And I think he's in some agreement with me about the politics of all this. i.e. Life has to be really bad and this has to be done once and quickly.....Gramsci called that Fortuna et Opportunta, or waiting for the time to be right and then giving the right legislation (or revolution in his case) a big shove.

HEALTH PLANS: Patient activism using the web

So I was sent an appeal by a grandmother upset that her grand-son was denied surgery by his insurer for what looks to be a pretty unpleasant condition, called Pectus Excavatum.  She has taken the campaign to the web.  I can't comment on this particular case or the surgery in general, other than to say that if it was my kid, I'd want the surgery done too.  But this is a wave of things to come.

POLICY: Another dribble on the single payer versus voucher issue

There's an interesting set of six letters about Krugman's article in the NY Times.  One of the letters is way off base, suggesting that Medicare limits what doctors can and can't do.  Well I suppose compared to a cash paying gazillionaire that's true, but anyone who knows anything about private health plans know that they are much tougher on limiting access to different types of care and different drugs than Medicare (not that it's done without good reason sometimes, but as my other post this morning shows sometimes there may be no good reason). The writer wonders whether Teddy Kennedy would want to be on Medicare. Unless I don't understand Senators' health plans, I assume he already is, and Krugman surely will be if he doesn't get assassinated by the loony right. It beggars belief how the Times can publish that sort of uninformed tripe which contains not one iota of evidence, but then again it never published my brilliantly argued rebuttal to a letter from AHIP's President about a previous Krugman column.

But one of the other letters is rather more interesting.  It says"

I find Paul Krugman's column disturbing. If 72 percent of Americans want a national health insurance program but insurance companies have the power to override that majority, what does that say about the health of our democracy?

Where can we get insurance for such an ailment?

Glenn Alan Cheney, Hanover, Conn.

Basically Mr Cheney is right. People like his namesake the VP have proved time and time again that access to power can be bought by moneyed special interests -- after all we still don't know and probably never will exactly what went on in those meetings about the energy bill, but it's pretty damn certain that Enron execs were writing US energy policy up until the moment that they just had to be repudiated.

However, I do have to take issue with the numbers quoted.  Essentially Krugman is quoting a number that has stayed relatively constant in various surveys, and crosses party lines.  The number is basically those who would in theory support universal health insurance.  These numbers are though not very important. A much better number is those who answer the three part question Harris has been asking for 20 odd years.  That question adds in the other part to "supporting universal insurance" by asking about the amount of change required in the system.  The three answers are broadly a) very minor change required, b) substantial reforms required, and c) complete rebuilding required.

The important answer is how many people are looking for a complete rebuilding. Because if there isn't a substantial group in favor of that, none of the reforms required to get to universal insurance can happen. That number tends to hover between 20% and 30% (and by the way it's way higher here than in any other English speaking country, which gives the lie to those saying that foreigners dislike their systems as much as Americans dislike ours). During the early days of the Clinton Administration, the "completely rebuild" number got up to over 40%.  More recently it also got into the higher 30s.  But for an Administration or Congress to have the will to defeat the special interests on health care, that number needs to be in the 40s or even 50s and stay there for a while. We haven't seen that, which is why we haven't seen real reform.

It will come, but the question is, how long will it take for things to be bad enough to drive enough Americans into the "completely rebuild" camp?

POLICY: Single payer versus vouchers: somewhat missing the point

In an op-ed called One Nation Uninsured Paul Krugman has given intellectual solace to all the single payer advocates out there and in his terms defined the serious argument in health poicy as being "between those who believe that the government should simply provide basic health insurance for everyone and those proposing a more complex, indirect approach that preserves a central role for private health insurance companies." Krugman is right in that this correctly excludes those avocating government-run health provision for all (and there aren't really any of these) and the numerous HSA/individual account backers who still can't do basic mathematics from the serious debate. (I'm having an offline conversation with a couple of these HSA promoters that may come to some resolution on that, but for now I still don't see how giving money to healthy people doesn't take it way from the sick ones who need it).

Krugman also puts some historical perspective to the analysis of why uninversal health insurance never passsed in this country. Yup, it's the AMA that's largely been to blame (and not just in 1945 either! They also helped stop it in 1917, 1933, 1965, 1971, 1977 and 1994 too). But Krugman largely ignores the doctors and says that it's the insurance companies to blame. Jonathan Cohn moonlighting from his New Republic gig over at TMP gives some more detail about the failure of some parts of the supporting coalition to back the Clinton plan, and the success with which some parts of the opposition (notably the small health plans and their brokers) dumped tons of horse manure on top of the proposal - notably "Harry and Louise". There's even been some comment from centrist Democrat Matt Miller suggesting that socialized medicine will finally really win support from big business.

This all apparently leads to a showdown between the voucher crowd, led by Vic Fuchs and Ezekiel Emmanuel, and the single payer advocates, whom Krugman is now supporting -- although in several other forums like this months Harper's he is backing the French model, which does have a mix of private pay, unlike Canada's. The key question is whether or not you maintain a private insurance sector, and whether or not politically you'll need the insurance industry's support to pass the legislation.

Clearly the way health plans and providers interact today is a total mess.  Witness this case in N.Carolina where the doctors are accepting the local Blues plan, but the hospital at which they are practicing isn't.  However, I actually think intellectually, there is room for independent advocates (e.g. plans) for patients to bargain or ally with providers, sort of like Enthoven's vision of multiple competing Kaisers under managed competition. But in the end I think this is a false distinction in terms of practical running of the system.  There is no infrastructure for that kind of competition between plans at the moment(i.e. over delivering better care not avoiding risk), and crafting the legislation to get to it is so complex that it's unlikely to be possible to get us there from our current system.

So the question is, if we are to get to universal health insurance, what are the circumstances that will get us there.  This is where the real lessons of the Clinton debacle come in.  The legislation will have to be done in response to a genuine crisis, and probably be done in the early days of a new Administration with a new Congress. Waiting for 18 months for the First Lady to draft something with her buddies won't cut it, not least because the crisis may go away. (That's what happened in 1994 and that's the real untold story of the Clintons' failure).

In that case there's probably no time to do anything more complex than to create a universal Medicare-for-all that takes in everyone, allows people to buy supplemental insurance at the margin to pay for nicer waiting rooms (as in the UK), and fixes prices for providers at the prevailing rate, with some tough caps in the out years to contain costs. That's how we'll get it done. 

The real issue will be how does it get reformed to be a logical system beyond that. It's taken the Brits 60 years to get to pay for performance, and we're only just starting for Medicare. The real trick to get to better care will be the incentives to change medical care delivery, once everyone is in the same insurance risk pool, and payers and providers can't run away from the cases they don't want.

But, and this is a huge "but", the level of crisis that we need to be at to get this new Adminstration and new Congress elected to change the health care system will need to be very large indeed. I don't think that we are anywhere close yet. Meanwhile we'll meander around with HSAs, more uninsured and health care coming up on the 2008 radar, but not as a defining issue. So methinks the apparent optimism of some of my more liberal colleagues that something is gong to get done here just because GM is hurting understates the inertia in the system.

I'll be writing more about the data behind the Clinton plan failure and what I think will constitute a crisis later.

HEALTH PLANS: Perhaps you shouldn't click on every Google Ad, with UPDATE on underinsurance

As you may or may not have noticed, in a (mostly failing) attempt to see whether I can make any money back off this blog, I've been running Google Adsense down on the left column. A certain commenter, let's call him Ron, suggested to me that this is an attempt for me to build my own insurance empire. While that may betray Ron's misunderstanding of how Adsense works (and look here for an amusing version of the same), one of the ads that ended up on THCB was for a very dodgy insurance company that wasn't so nice.  Take a look and of course caveat emptor.

UPDATE: Meanwhile, Health Affairs today has a Commonwealth Fund study that estimates the number of underinsured at 16 million. By my very casual glance at the Press release it seems that they may only be talking about those with inadequate insurance who actually needed it. My guess is that overall underinsurance (e.g. not having enough to pay the bills in the case of a bad trauma) is much greater.  But then again, it's the flow of people through un- and under- insurance that's such a big issue, with more than 80m uninsured for at least 3 months in a 4 year period.

QUALITY: Want to avoid medical errors? Pick a profitable hospital

Just found this gem.  Apparently an AHRQ study looked at the rate of medical errors in Florida hospitals and discovered that the more profitable hospitals (situated in general in areas where there were wealthier patients of course) had fewer medical errors. Intuitively this makes sense.  While any hospital can make a screw-up, such as washing surgical instruments in used elevator oil (yup really happened at Duke -- read this), in general medical errors are a symptom of incomplete process engineering, and the more successful companies in any field, which also tend to be the richest, are likely to run better -- or at least closer to a specified process. Of course part of that process is having the money for the systems and the people to put that process in place.

So another good reason to choose your income level, (and by extension that of your parents) carefully.

I'll have much more tomorrow on Krugman's entry into the single-payer fray.  But you'll all be busy on the "Michael Jackson gets off on little boy('s charges)" headlines.

QUALITY/TECH: CHCF on Chronic Disease Care

I'll review this in a little bit (getting a bit of a slow start this AM), but I wanted THCB readers to know that California Healthcare Foundation has published some more excellent studies with very practical applications. These ones focus on chronic disease. There are three. One on helping patients manage their own chronic conditions, a second on the tools available for patient self-management, and a third on the benefits and challenges of using telephone based chronic care management techniques (which is where the state of the industry is now).

Excellent practical stuff from an organization that is focused on helping make real positive change.

POLICY: PRI has a blog, almost.

Sometimes you just wonder how these press release lists get put together. The Pacific Research Institute, which with its fellow traveler organization the Fraser Institute, has been issuing nutty and just plain wrong "research" about Canadian health care for years, decided to start sending me press releases today. They now have their own blog (well it's not alive yet but a press release is as good as, dontcha think?). The blog will explain why importing drugs from Canada is a bad idea and why paying more for drugs is a good idea.

Well as they're nice enough to send me the release I went and looked at their annual report, and if you like pictures of Maggie Thatcher you should go look there too. It does worry me a little when Sally Pipes can only find Rick "Man on Dog" Santorum to quote effusive things about her health care work, but I guess you get praise where you can.

However, their press release also says that they solicit corporate contributions from the health care industry. No biggie, as I do that too (although I call it consulting work!), but you might get the impression that the "research" PRI conducts probably fits the views of certain parts of the health care industry very well. So well that I'm a little surprised PRI only manages to get 15% of its $4.1m budget out of the corporate sector--although it gets another $2m odd from "foundations" which may well be corporate-controlled ones too. But they're not honest enough in the report to say who it is who's coughing up.

What you really see from reading the report is that PRI has been somewhat effective in turning a small amount of money into either effective policy interventions or totally muddying the policy waters (take your pick). The end result is that whenever Canadian health care comes up, there is a loony cry from the right that manages to obscure a few basic facts, and makes sure that no rational conversation can be had here about real health reform. Even though the genuinely independent Lewin group showed that single payer would save money in California--a report that sank without trace. So to that extent, this little corner of the vast right wing conspiracy (in San Francisco no less!) is doing its job. Pity that PRI's claim about individual freedom being the be-all and end-all don't appear to have transmuted over to a stated position on the drug war or medical marijuana.  Perhaps they don't notice where they are. The Independent Institute, a more intellectually honest libertarian think tank across the Bay has no such qualms.

POLICY: Fuchs and Emanuel on vouchers

In an article called  "Solved!" Vic Fuchs (and new-ish partner) Ezekiel Emanuel go into much more detail about their plan for creating a VAT-funded voucher system for health care. I'm moderately in favor of vouchers for health care and education so long as they are indiscriminate between public and private institutions (i..e don't take money from public schools and give them to private ones). In fact the best of all worlds would have no "public" provision of either education or health care, but a voucher system that was closely controlled to make sure that inequality of geography and class was corrected. In other words you'd get a more valuable voucher if you lived in the ghetto than if you lived in the suburbs, which would encourage health plans and schools to set up there.

Having said that, I don't think that Fuch's plan has much chance of success in the medium term because I don't think that Americans care enough about universal health care. More likely will be some kind of incremental legislation, such as that being discussed in secret by Heritage, Families USA et al. As I've railed many times on THCB, if it's not universal and compulsory, no system will work in either reducing costs or reducing the number of uninsured, because the producers can keep on putting the prices (and services) up and the net result will be more people unable to afford insurance. So an incremental approach will not solve the problem for which a solution is being demanded (which is rising costs for the middle class rather than uninsurance for the lower class).

So in the long run this incrementalism will lead to a single-payer government funded (and possibly provided) system, which will have a defined and fixed budget--and may be administered via a voucher system  But it will take us a long time, or a national crisis to get there.  Who was it who first told me that health care reform only happened in times of national crisis?  Vic Fuchs.

TECH: Firefox effed up?

Is it just me or is the latest release of Firefox 1.0.4 a disaster?  Ever since I downloaded it, Firefox has been crawling compared to IE--literally taking 10 times as long to download a web site.  So much so that I've abandoned it.  I've trawled the web, changed a few settings based on some stuff I've read, but it's still a disaster.  Any ideas?

PHARMA: A start-up data success? IMS Health buys PharMetrics

This one may be a little too inside baseball for some of you, so don't be afraid to skip it.  However, if you care about pharma marketing, read on.

Yesterday IMS Health said it was buying PharMetrics. PharMetrics is a company that succeeded where my old company i-Beacon, and several others backed rather better, failed in creating a business for longitudinal patient data. What that means is that it linked medical claims and Rx claims data about the same people over time.

Theoretically that tells a drug company whether their drug is getting its "share" within its disease category and also whether its drug is working in reducing medical claims. (You remember that theory about drugs improving care quality and lowering cost?) It's also supposed to tell a health plan whether its disease management efforts are working, or what disease management plans are working elsewhere, although local rival IHCIS concentrates more on that market. (i-Beacon BTW matched PharMetrics-type Rx and claims data with other consumer data in a very clever and legal way to help score DTC marketing--not that we ever really got the product to market).

PharMetrics gets its data as a by-product of a weird agreement with a tools company called Symmetry Health, and receives data on roughly 50 million people via lots of health plans. From my recall (which is some years old now) they don't know who the people are (other than having a unique plan identifier so that they know it's the same person). Therefore they a) don't have a way of tracking the people once they leave their plan, which presumably makes the data somewhat less robust over time as most people change plans every couple of years, and b) can't fulfill the pharma marketing wet dream of telling the detail reps which patient at which doctor ought to be on their drug but isn't. Of course getting to that stage would be unethical, not to mention illegal! But the basic problem with these longitudinal patient data sets is just that. They can tell you what might work in general but cant point your sales people to specific things to do in particular cases because that would mean identifying individuals. Of course eventually if we all get electronic medical records, some organizations which have  legitimate right to do so will be doing that.  In fact Active Health Management, bought by Aetna last month, does just that--but they are then by definition confined to disease management and can't sell that data to the pharma companies--who are the best market.

IMS Health of course has the "specific" data base on doctors and their prescribing habits, and it's not only wrapped into telling the pharma sales forces what to do, but is also a direct component of how the sales forces' compensation is scored. That's why IMS is the best (and most profitable) franchise in all of information services and why big and small companies (like Arclight, PharMetrics and i-Beacon) continually take a run at them--often with the intention of getting bought.

PharMetrics seems to have achieved that goal. I don't know specifically how well it was doing but with 75 people and probably $10-20m in revenue, it probably went for around $50m. Of course that's pure speculation and we won't know the real numbers till IMS next 10Q comes out, but the main thing is that the VCs who put in $30m over time got out alive.  And who knows, maybe they all did much better, which will of course only encourage others to get into the ring.  And that's much of the driver behind the grimy little sector of pharma data analysis.

PHARMA: Is Pfizer's Black Knight on the way out?

So the slow burn of Peter Rost's time at Pfizer appears to be picking up. The NY Times reports that he's essentially been comparing him with the Black Knight (in Monty Python and the Holy Grail) in not noticing how bad his situation really is. But in the NY Times article a couple of interesting things are revealed. It's already known that Rost sued and beat his previous employer Wyeth in a whistleblower-type scenario when Wyeth was underpaying taxes.  Rost may also be involved in some kind of a whistle-blower suit currently, as according to the Times "Pfizer disclosed that the Justice Department had opened an investigation into its marketing of genotropin, the growth hormone Dr. Rost was responsible for selling at Pharmacia". Presumably if Rost was a bad guy in that scenario Pfizer would happily fire him, so it must be assumed that he's probably a whistleblower or at least neutral.

The whole thing about reimportation is of course ridiculous. In Europe the courts have just ruled that "parallel trading" is legal, and you don't see the drug industry give up selling its products in Europe because of that. If Canadian imports were legal here, there wouldn't be that much difference to the current market.  But that's an old discussion and we know the positions there are not going to change much.

The interesting point is that Rost gets $600,000 a year to do whatever he's doing at Pfizer, and of course he can't leave that and get anything like as much anywhere else. Those of you who consider that you're selling your souls to big pharma/corporate American might wonder whether you are getting your fair share!

BLOGS/TECH: THCB week off over, more or less

Your host took a (he believes) well-earned break in Europe last week  following some work over there (and no it wasn't for the NHS). I'm actually still there (here?) having randomly found wi-fi in a wi-fi less world before my flight back to the states tomorrow.  Anyway, I did all the eastern Europe touring I should have done 20 years ago when I lived here, and I recommend Prague heartily.

The main thing of interest that happened while I was gone was that the rumors of IDX's problems in the UK  (mentioned several times in the excellent HISTalk blog) indeed were true. Fujitsu, the general contractor in the southern region fired them, even though their replacement (another win for Cerner) has had its own issues with the "meet and greet" appointment system. (Yeah I know it's not called that).

Cerner's stock price is up some 30% since March, which suggests that Wall Street has decided who the winner is in the HIT game. As my Fiercehealthcare editorial last week suggested, it's probably a matter of when rather than if one of the bigger tech companies (Oracle is a persistent rumor) decides that they want them.  However, at a PE of 37, Cerner is pretty pricey!

My next real work is on the subject of ePrescribing. So if that's an interest of yours please drop me an email. Hope you didn't miss me too much, and I look forward to being a little more attentive in the coming weeks.

Finally