Because, says a paper published through the National Bureau of Economic Research, nursing homes have an easier time hiring minimum-wage nursing assistants. At least that's part of the reason. (People also drive less during recessions, so the risk and incidence of vehicular death goes down.)

Robin Hanson explains:

It seems that the puzzle of why death rates rise in good economic times is nearly solved. There’s an effect of increased driving deaths from increased driving, but the main effect is that in good times nursing homes have to compete more for minimum wage nursing assistants. Apparently a one percentage point cut in the unemployment rate leads to three percent fewer nursing assistants, which increases the national death rate by a half percent (which cuts about three weeks of life per person):

Posted by Jay Hancock at 6:24 PM | Permalink | Comments (2)
Categories: Health Care
        

Judges sentencing doctors convicted of implanting medically unnecessary coronary artery stents are not messing around. On Thursday U.S. District Judge William D. Quarles Jr. called overstenting by Dr. John McLean "a crime of greed" and gave him eight years in prison. McLean was convicted of falsifying patient records in connection with needless stents put in at Peninsula Regional Medical Center on the Eastern Shore.

The hospital itself settled recently with the government without admitting liability. But in an August news release U.S. Attorney Rod Rosenstein said there was a "failure of senior medical staff at PRMC to follow up on evidence presented to them through the complaints of staff in the cardiac catheterization laboratory about the medically unnecessary nature of the procedures that Dr. McLean was performing."

Also this week Dr. Mehmood Patel in Louisiana appealed his 10-year sentence for installing unneeded stents. From the Advertiser.com:

A three-judge panel from the 5th U.S. Circuit Court of Appeals didn't immediately rule after hearing arguments in Dr. Mehmood Patel's case.

In December 2008, a jury convicted Patel of 51 counts of health care fraud but acquitted him of 40 other counts.

Prosecutors say Patel lied to patients about their medical conditions, performed risky tests and procedures, falsified medical records to make them appear justified and then fraudulently billed insurance companies for the work.

Posted by Jay Hancock at 8:45 AM | Permalink | Comments (0)
Categories: Health Care
        

For today's column on alleged fraud at Kernan Hospital, I interviewed Dr. Scot Silverstein. He's an MD, consultant, adjunct prof at Drexel and an expert on electronic patient records.

The U.S. attorney for Maryland said that Kernan's secondary diagnosis in 2008 of a severe, rare kind of malnutrition was a bogus attempt to increase reimbursement. The more severe a patient's condition, the more money hospitals get paid. The disase, kwashiorkor, is rarely seen outside of developing nations, but in 2008 Kernan was diagnosing one out of every eight patients with kwashiorkor. From the column:

But somehow Kernan experienced an apparent kwashiorkor outbreak starting in 2006, the only Maryland hospital to do so. Its cases of kwashiorkor as a secondary diagnosis grew a hundredfold, from three in 2005 to 358 in 2008, according to data from the state Health Services Cost Review Commission.

That was more than a third of all the diagnosed kwashiorkor cases statewide. At Kernan, 12.7 percent of all patients were diagnosed in 2008 with the rare ailment. At all Maryland hospitals, on the other hand, only 0.13 percent of that year's patients had kwashiorkor on their charts, according to the HSCRC data

The increasing computerization of medical records may be raising hospitals' tendency to do this sort of alleged "upcoding." When hospital personnel enter cases into the computer, prompts will come up nudging them to add disease codes that will increase reimbursement. Silverstein, blogging at Health Care Renewal, says that in any case the spike in kwashiorkor diagnoses must have been a red flag for government auditors, who have their own software to identify this kind of thing. Silverstein:

I note that I could have easily advised the hospital not to use the diagnosis of kwashiorkor or do these things, had I been on staff there. I would have opined that it would stick out like a sore thumb via the algorithms payers use to detect fraud, e.g., via sudden, strange changes in claims. One wonders why nobody else gave that advice ... (fear?)

Here's a commenter on Silverstein's blog:

For years I've been jumping up and down telling folks that this was bad news. Kwashiorkor doesn't exist in developed nations. It is simply wrong to code for it 99.99% of the time.

Everyone seems to be blinded by the potential to get more money and taking the risk to not be audited!

Posted by Jay Hancock at 11:20 AM | Permalink | Comments (0)
Categories: Health Care
        

I often call Obamacare "Obamacare," and I usually get objections from people who say it's a poltically laden term, shows my bias etc. Actually for me it's just a convenient shorthand. Fits better in a headline than the Patient Protection and Affordable Care Act. I was for Obamacare, although it's certainly not an example of ideal policy.

Now, as Kaiser Health News notes, groups in Colorado are trying to make the Obamacare brand appealing and positive:

But now, two nonprofit advocacy groups, ProgressNow Colorado Education and the Colorado Consumer Health Initiative, are trying to take back “Obamacare,” painting it as a positive brand in a new campaign (complete with its own Twitter feed and hash tag, #thanksobamacare) launched Monday.

The campaign highlights 10 reasons people should be thankful for the health law. Among them: allowing people younger than 26 to stay on their parents’ health insurance plans and stopping insurers from denying coverage to children with pre-existing conditions (the law does the same for adults beginning in 2014).

Posted by Jay Hancock at 11:13 AM | Permalink | Comments (1)
Categories: Health Care
        

Great story from AP on how the government is stumbling on fighting possible Medicare fraud:

Medicare Yanks Licenses, Gives Them Right Back Regulators fighting an estimated $60 billion to $90 billion a year in Medicare fraud frequently suspend Medicare providers, then quickly reinstate them after appeals hearings that government employees don't even attend, according to an Associated Press review. Federal prosecutors say the speedy reinstatements — though helpful to legitimate suppliers who get snagged on technicalities or minor violations — amount to a missed chance to cut off the flow of taxpayer dollars to bogus companies that in many cases wind up under indictment

And:

Making matters worse, Medicare officials have failed to collect a single cent from the security bonds that were instituted two years ago specifically to discourage crooked providers from vanishing at the first sign of trouble from regulators. Millions of dollars sit unrecovered; officials blame the delay on personnel changes

Hat tip Kaiser Health News

Posted by Jay Hancock at 10:16 AM | Permalink | Comments (0)
Categories: Health Care
        

Still getting emails on Sunday's column, "Fixing America Needs Contributions From Everybody." Here's one from Paul Belz, an Army reservist and insurance agent who is surprised that his military Tricare health plan requires no premium contribution from him.

He wrote to the magazine of the Military Officers Association of America, he says, and suggested that retired officers ought to contribute a little more in the way of premiums, co-pays etc. The response was very negative, he said. Here is his entire email:

Hi, Jay..

I found that recent article very interesting...!

I have a good example of your point...

I am a 62 year old, retired Army Reserve Officer (part timer)..still working..I sell Property and casualty insurance...I receive a small pension for my service, and get Tricare health insurance.
.
I pay NO PREMIUM for Tricare..I have NO CO-PAYS, then a 25% coinsurance , to a max expense (like a deductible) to $3,000 out of pocket..It is very generous...!!

Recently, I wrote a letter (to the editor) of an organization that I belong to..the Military Officers Association of America (MOAA), suggesting that we, as retirred officers, ought to be willing to contribute a little to the whole "address the debt'"situation...perhaps pay some premium, accept co-pays, etc..

In Feb, 2011, my letter was included in the magazine..

In subsequent months' letters to the editor... membership OVERWHELMINGLY responded that they vehemently opposed ANY contribution/resolution assistance

Continue reading "To help U.S., veteran benefits should be cut, vet says" »

Posted by Jay Hancock at 6:06 AM | Permalink | Comments (4)
Categories: Health Care
        

Author Kathleen Sharp says the government isn't doing enough to fight health-care fraud, which some estimate costs hundreds of billions of dollars a year:

At the beginning of this year, the Justice Department had more than 1,300 whistle-blower cases under investigation, the bulk of them related to pharmaceuticals, hospital chains and health care companies. That’s up from the 900 or so cases that were stalled during the end of the Bush administration. To be fair, the department has long been understaffed when it comes to health care investigations. But in 2009, the Justice Department and the Department of Health and Human Services were given an additional $198 million to combat health care fraud. Neither the money nor a new task force seem to have helped much.

Last year, the Justice Department recovered $3 billion in false claims, $2.5 billion of that from health care cases. But that’s just a drop in the bucket. It’s gotten so that even if a case is settled, many pharmaceutical companies simply write it off as the cost of doing business.

Posted by Jay Hancock at 6:04 PM | Permalink | Comments (0)
Categories: Health Care
        

I don't know enough about the Maxim case, covered by Andrea Walker in today's paper, to have an opinion on whether it should have been debarred from the Medicaid program. I do know that time after time after time, defense and health-care contractors cheat the government and reap only mild consequences.

Check out the Project on Government Oversight's Contractor Misconduct Database. Lockheed Martin is at the top of the list, although a quick glance seems to show that most of the violations are relatively minor. Even so, at many companies serious fraud takes place and still the companies are allowed to continue doing business with the government. I quote FraudBlawg:

There have been zero debarment actions in the past fifteen years against the government’s largest (top 100) suppliers of goods and services, despite hundreds of billions of taxpayer dollars lost to fraud. In fact, many of the worst offenders continue to receive taxpayer money and continue to be awarded the largest government contracts.

Posted by Jay Hancock at 9:15 AM | Permalink | Comments (1)
Categories: Health Care
        

USA Today reports that federal prosecutions for health-care fraud are on pace to rise 85 percent this year, quoting assistant AG Lanny Breuer as saying the 24 trial convictions for Medicare fraud so far this year already exceed all the trial convictions last year.

"That's just a stunning number when you see it in the first eight months," Breuer said of the task force. "We're just going to build on this model, and we're going to hold those responsible who are stealing from the government."

Maybe. But when measured against the volume of Medicare fraud out there, it's not that impressive. Justice needs to get even more aggressive against health care fraud, and one hopes Medicare will be very diligent about moving away from its "pay and chase" model to screening out obvious scamsters from the start.

UPDATE: Justice Department spokeswoman Alisa Finelli says:

Your blog post on health care fraud prosecutions uses the trial conviction number for just one of our fraud efforts – the Medicare Fraud Strike Forces operations. That is not the total number of trial convictions for all DOJ prosecutions (and of course there is a much greater numbers of convictions resulting from guilty pleas). I wanted to flag for you because your blog currently presents the statistic without the reference that it is for strike force cases alone. And to the extent that your blog suggests the number isn’t high, I wanted to make sure you were aware that the overall DOJ convictions for health care fraud is much greater.

Posted by Jay Hancock at 9:14 AM | Permalink | Comments (0)
Categories: Health Care
        

The evidence showing the efficacy of the grueling Hipec treatment, where they open your lower parts and pour in heated poison to treat cancer, is extremely dubious. What's not in doubt is that the procedure makes a lot of money off desperate patients for doctors and hospitals, at taxpayer expense.

The cost of the surgery and Hipec, including hospitalization, ranges from $20,000 to more than $100,000, doctors said. While Medicare and insurers generally pay for the operation, the heated treatment may not be covered. But doctors added it may be if it is described merely as chemotherapy.

Posted by Jay Hancock at 9:18 AM | Permalink | Comments (1)
Categories: Health Care
        

A new report in the Journal of the American Medical Association furnishes new evidence of unnecessary stent procedures.

UPDATE: Here is the story in today's Sun:

From CNN:

Researchers from several major heart centers analyzed more than half a million PCIs performed in the years 2009 and 2010, at more than a thousand hospitals. Of those done in acute situations, nearly all – more than 98% – were deemed “appropriate,” according to the study. However, many PCIs in non-emergency situations were not recommended under guidelines developed by a leading group of heart experts. Among non-acute cases, 50% were deemed “appropriate,” 38% “uncertain” and 12% “inappropriate,” according to the study. Most of the inappropriate procedures were done on patients with low-risk heart conditions.

"Acute situations" are when a patient is in the middle of a heart attack. Stent abuse takes place when patients are stable and often don't need one. So 12 percent of the nonacute cases were inappropriate -- that's 20,000 cases. What's more:

Researchers also found that some hospitals are far more likely than others to do unneeded PCIs. Jneid calls this “troubling” and says it suggests that some patients are being pushed into procedures for the financial benefit of doctors or hospitals. “You hate to say that, but it’s a possibility.”

The inspector general at the Centers for Medicare and Medicare Services needs to investigate the hospitals installing unneeded stents at taxpayer expense and patient risk. So far the CMS IG office has shown little sign it is moving aggressively against the kind of stent abuse that was allegedly done on a massive scale by Dr. Mark Midei and St. Joseph Medical Center.

UPDATE: Here is another case of alleged "overstenting" in Tennessee. As in other cases, the irregularities seem to have been brought to light by a whistleblower, not government investigators.

Posted by Jay Hancock at 1:16 PM | Permalink | Comments (2)
Categories: Health Care
        

Pfizer is cutting R&D by a fourth and laying off thousands of researchers. Of course its stock went up on the announcement, which will boost profits in the short term but probably depress them in the long term. But nobody cares about the long term anymore. Certainly not many CEOs, whose personal business model is to goose profits in the short term and siphon as much money as possible into their personal accounts as possible. And not many shareholders, either, who have become less and less long-term investors.

Pfizer's former head of research, John Mattina, told Reuters he was surprised by the move:

Trimmed down to $6.5 billion to $7 billion, Pfizer's research budget will represent around 10 to 11 percent of the company's estimated revenue in 2012.

"That's a pretty low percentage for the largest pharmaceutical company in the world," said LaMattina, now senior partner at healthcare venture capital firm PureTech Ventures.

"This industry historically has spent anywhere from 15 to 20 percent of top-line sales in R&D," LaMattina said. "It's their lifeblood. If you don't have new products you don't have a business anymore."

Posted by Jay Hancock at 8:18 AM | Permalink | Comments (3)
Categories: Health Care
        

Krugman is scoring some points by noting that Medicare spending, for all its escalation, has risen less than premiums on private health insurance. There are many reasons for this, including private insurance's profits and duplicative administrative costs.

But one huge reason for the private-insurance inflation doesn't especially cast credit on Medicare and Medicaid and is unmentioned by Krugman. Medicare and Medicaid reimbursement for docs and hospitals is notoriously low and getting skimpier. Hospital officials frequently complain, plausibly, that Medicare payments don't cover their expense. So they raise costs for private insurers to compensate. This kind of cost-shifting has been going on in most states for decades. It doesn't happen in Maryland because of this state's unique system in which the Health Services Cost Review Commission sets one hospital price for all payers.

But that's the exception. In other states, the ability of Medicare to shuck expense off on the private sector isn't exactly great testimony to the program's ability to control costs. Here is Paul Levy from the Not Running A Hospital blog:

Here's where Mr. Krugman is wrong. The Medicare rates paid to doctors and hospitals are set by government fiat. They are based on Congressional appropriations, political decisions resulting from the give and take of the legislative process. Ditto for Medicaid rates set by the states. They have little or no relationship to the cost of providing service to patients. When there is a shortfall in Medicare and Medicaid revenues, the difference is made up by the rates paid by private insurers.

Posted by Jay Hancock at 6:45 AM | Permalink | Comments (5)
Categories: Health Care
        

Medicare fraud ought to be puke-inducing for any taxpayer who understands what's going on. Largely at the direction of Congress, Medicare pays bills first -- even bogus, highly suspicious bills -- and asks questions later, if at all. Now, AP reports, Medicare is installing the kind of antifraud software that credit-card companies had 25 years ago.

The technology upgrade should help deter flagrant abuses such as the small clinic that suddenly starts billing more for a particular outpatient procedure — intravenous infusions, for example — than major hospitals in its area. But it’s not likely to help crack sophisticated schemes that involve outwardly respectable companies with the expertise to cover their tracks.

Medicare “is putting in place the kind of computer program it should have had in 1980 or earlier,” said Patrick Burns of Taxpayers Against Fraud, a nonpartisan group that supports whistleblowers who expose corporate scams against the government. “The bad news is that the largest Medicare and Medicaid frauds are designed at the highest levels of companies, with accountants, billing experts and salespeople smoothing over the paperwork so that it will slide past all the proctors.”

Posted by Jay Hancock at 10:06 AM | Permalink | Comments (3)
Categories: Health Care
        

A great essay in The New Republic on what's wrong with American health care by Daniel Callahan and Sherwin Nuland.

Ours is now a medicine that may doom most of us to an old age that will end badly: with our declining bodies falling apart as they always have but devilishly—and expensively—stretching out the suffering and decay. Can we conceptualize something better? Can we imagine a medicine that is more affordable—that brings our health care system’s current cost escalation, now in the range of 6 percent to 7 percent per year, down to 3 percent, which would place it in line with the annual rise in GDP? Can we imagine a system that is less ambitious but also more humane—that better handles the inevitable downward spiral of old age and helps us through a somewhat more limited life span as workers, citizens, and parents?

The answer to these questions is yes. But it will require—to use a religious term in a secular way—something like a conversion experience on the part of physicians, researchers, industry, and our nation as a whole.

And they tell the truth that is taboo in U.S. politics:

Unhappily, however, some rationing and limit-setting will be necessary. There is no way the Medicare program can survive unless it both sharply cuts benefits and raises taxes. Certain benefits can be cut directly or indirectly—directly by reducing payments for treatments, or indirectly by increasing co-payments and deductibles to a painful level, sufficient to discourage people from insisting on them.

Posted by Jay Hancock at 1:01 PM | Permalink | Comments (2)
Categories: Health Care
        

As if any more evidence were needed. When prescribing doctors profit from expensive procedures through an ownership interest in radiology equipment, they prescribe more of those procedures. From MD News:

Patients with low back pain in the care of primary care physicians or orthopedists who own or lease magnetic resonance imaging (MRI) equipment are more likely to receive an MRI, according to a study published online April 21 in Health Services Research...

The investigators found that acquisition of MRI equipment by a physician had a strong correlation with patients receiving MRI scans....

"Orthopedists and primary care physicians who begin to bill for the performance of MRI procedures, rather than referring patients outside of their practice for MRI, appear to change their practice patterns such that they use more MRI for their patients with low back pain," the authors write.

Posted by Jay Hancock at 2:40 PM | Permalink | Comments (2)
Categories: Health Care
        

Liberals are making fun of Sen. Scott Brown for flipflopping on the Paul Ryan Medicare plan. They are entitled to it. But Brown makes one point everybody ought to be able to agree on: Woodlawn-based Centers for Medicare and Medicaid Services need to change their payment model. Instead of presuming invoices are legitimate and paying everything that lands in the mail or computer server, they need to presume everything is a fraud and not pay any providers unless they can establish themselves as legit.

This would slow down payments and make providers unhappy. Too bad. How much of this would require congressional action I do not know. I was under the impression that Congress basically told CMS not to delay payments. Brown:

The Government Accountability Office has estimated that nearly 10 percent, or $47 billion, of annual Medicare spending is nothing but waste, fraud or abuse. Attorney General Eric Holder has put the number higher -- at $60 billion. We need Medicare administrators to work to prevent these improper payments -- instead of the existing "pay and chase" model that makes the system so susceptible to fraud.

Posted by Jay Hancock at 10:57 AM | Permalink | Comments (1)
Categories: Health Care
        

The push-back by Chesapeake Urology and its patients against Tuesday's column on self-referral has already started. A former colleague and CU patient emailed me yesterday about what great treatment he received. Today there's a letter to the editor from the pastor of Zion Baptist Church.

Last year, I was diagnosed with prostate cancer. I was concerned, but knew exactly where to turn. Over the past two years, I had worked first-hand with Chesapeake Urology Associates, an organization that brought free prostate cancer screening to my congregation and to other Baltimore City communities.

This is completely beside the point. I'm sure there are thousands of satisfied Chesapeake Urology patients. Why not? They aren't paying the tens of thousands of dollars for the IMRT treatment (taxpayers and insurance companies are) and they're in no position to judge whether that was the right therapy.

The doctors there are no doubt very nice. I hear they have a buffet or something for patients waiting to get zapped. But happy customers do not refute arguments against the conflict of interest that self referral represents. If you want to present evidence showing that in general self-referring doctors do not overutilize the system, fine. (I don't know of any.) If you want to try to show that self-referral saves the system money on net by keeping treatment under one set of docs, great. (It doesn't.) If Chesapeake Urology wants to release patient treatment data to show that it doesn't conform to what the research shows generally about self-referral, great.

But saying "my treatment there was really successful and convenient, and what wonderful caring doctors!" does not end the discussion.

Posted by Jay Hancock at 11:12 AM | Permalink | Comments (6)
Categories: Health Care
        

Robin Hanson notes that the percentage of autopsies hospitals perform on their (presumably) unsatisfied customers has plunged. In the 1960s hospitals did post-mortems on half their patients who died. Now it's only 5 percent, and many hospitals don't do autopsies at all, according to the piece he cites in the Washington Post.

Hanson suggests that the rise of malpractice litigation caused the decline in autopsies. Why produce evidence for the plaintiff's bar? And he does not believe the trend is complimentary to the medical profession. Hanson:

The idea that we could afford autopsies before 1970, but now they are too expensive to afford is pretty crazy. In 1970 the US spent 75B$ on medicine (7% of GDP); we now spend 2500B$ (18% of GDP). A pretty obvious explanation for fewer autopsies: docs don’t like being proven wrong. Such dislike can lead to lawsuits, and generally make docs look bad. This can explain doc “fear of litigation”, dislike for autopsies that might disagree with tech diagnoses, and lobbying to cut accreditation rules requiring autopsy funding.

Could there be any clearer evidence that docs care more about getting paid than about healing patients, yet the public can’t bring itself to imagine docs are that selfish?

Posted by Jay Hancock at 5:24 PM | Permalink | Comments (2)
Categories: Health Care
        

Mostly positive response to Sunday's column on sacrificing to fix Medicare. Thanks for all the feedback. Unfortunately some of the causes cited by readers of high health costs -- illegal immigrants, Viagra prescriptions, prescription drugs in general -- are a small part of the problem. Several readers smartly propose expanding Medicare to those 55 and over or to everybody -- ideas that were brought up in the discussion about Obamacare.

One reader suggests I don't call it Obamacare, saying that's pejorative. But nobody knows what the Affordable Care Act is. Here are a few emails:

You are absoslutely right , Medicare is in deep truble and causing trouble for our country. You are also right I suspect, that some forme of tax increases and benefit cuts are needed. There is one other approach in additon to the above that will help the solvency of Medicare. Interstingly, Paul Ryan's prorposal contains a tiny nudge in that direction. My suggestion is to lower the age of eligibility for Medicare immediately to 55. There are approximatley 20 million people between the age of 55 and 65. Adding this cohort of younger relatively healthier premium paying subscribers to Medicare who require statistically far less in serivces than their older counterpart will add a great deal of money to Medicare's bottom line.

And:

I beg to differ with your math. I agree that I paid in $ 55,000 into the system, and I now expect $ 161,000 back. But if I had been allowed to invest those payments I made to Medicare instead into my account in the Stock Market, I would have more than the $ 161,000 needed to cover my needs. The same is true for Social Security. If the government had invested my payments the way I could have done it, I would not worry.

And:

People say that costs are going up because of all the illegal aliens using the system. If so, why don't the hospitals triage these folks when they come in with the flu and send them to a low cost clinic instead of treating them in a $500/hr. facility? For the most part, the ER is a cash cow for hospitals.... too many people use the ER for their family doctor.

That leads to the question of why medical costs are going up and up. The docs I've discussed this with say it's prescription medications.

And:

Continue reading "Readers: Medicare is in trouble, must be fixed" »

Posted by Jay Hancock at 7:00 AM | Permalink | Comments (2)
Categories: Health Care
        

Far less hate mail in response to Sunday's Medicare column than expected. I'll publish more responses on Tuesday, but here is my favorite. Always refreshing to hear someone honest enough to give "evidence against interest" -- to argue against a program that benefits the arguer in favor of some higher principle.

He makes a good point about the fraud. Many patients see funny stuff going on but are reluctant to second-guess "care givers" who are ripping off the system.

That was a great article on "Fixing Medicare" in Sunday's paper. You really laid it out openly and honestly.

Something has to be done. I
am 92 and I know that I am taking out much more than I ever put in.
The one thing that no one seems to know how to fix or even address is
the terrible amount of waste and fraud. Over the years I have seen
many questionable bills submitted on my behalf but have not known how
to address these issues without jeopardizing my own medical care.

Posted by Jay Hancock at 9:42 PM | Permalink | Comments (3)
Categories: Health Care
        

Len Lazarick of MarylandReporter.com writes that "health insurance brokers who were afraid the O’Malley administration’s health benefits exchange would put them out of business are now reasonably happy with the bill that passed the House of Delegates Monday."

The bill would basically put the decision off for study. But if the health insurance brokers and the state health exchange both keep up a robust business, we'll have added another layer of health-care administration to the country that already has way too much. I don't blame the brokers for looking after their interests. And government health exchanges are a necessary part of Obamacare. But the practical effect will be even more guys sitting at desks (rather than taking care of patients) adding to the cost of health care. Single-payer system, anybody?

Posted by Jay Hancock at 9:59 AM | Permalink | Comments (3)
Categories: Health Care
        

Tricia Bishop reports on allegations against Baltimore ophthalmologist Dr. John Arthur Kiely, accused by the U.S. government of performing unnecessary eye procedures at an outpatient facility owned by Bon Secours Hospital.

There's a lot of this going around. The Sun has reported extensively on Maryland cases in which Dr. Mark Midei and Dr. John R. McLean are accused of implanting unnecessary coronary artery stents. Now there is a new stent case in Pennsylvania, according to the Pittsburgh Post-Gazette.

After discovering 149 coronary stent implants in 141 patients in 2010 that may not have been medically necessary, Excela Health hospital system is offering free help to patients directly affected and advice to other people who may be concerned about similar health conditions.

Robert Rogalski, Excela chief executive officer, on Thursday confirmed that two Westmoreland Hospital cardiologists who are no longer members of the Excela staff, Ehab Morcos and George Bou Samra, were found to have performed the procedures after concerns arose among the medical staff at the Greensburg hospital.

"Free help to patients directly affected." How nice. If these allegations are true, how about compensation for the risk of an unnecessary procedure and the damage of a permanent piece of unnecessary hardware? No indication as to whether the hospital is examining these guys' cases prior to 2010. If that's the case, it would seem to be trying to limit its malpractice liability in a similar way to St. Joseph Medical Center, where Midei did his work. St. Joseph reviewed two years of cases.

Posted by Jay Hancock at 9:08 AM | Permalink | Comments (3)
Categories: Health Care
        

The legislature is holding hearings this week on bills that would allow orthopedists, urologists, cardiologists and other treating physicians to own expensive diagnostic and treatment machines and order their patients to use them. Maryland's highest court recently found that Maryland law prohibits this, and for good reason. History shows that when docs own the equipment, the equipment gets overused. The more procedures you order for your own machine, the more money you make.

The only sane arrangement is to separate the doctors prescribing expensive treatment from the doctors delivering expensive treatment. That removes the profit motive. Here is last month's column on the subject.

But the docs who own these machines are lobbying heavily for the legislature to create a loophole. Here are excerpts from a purple-prose form letter docs are sending to General Assembly members, with my comments in parentheses.

Senator ______,

I am writing to urge you to support Senate Bill 808, in order to protect the rights of patients to choose to have medically necessary MRI and CT scans and radiation therapy for the treatment of cancer in their own treating physicians offices like patients in every other state in the country.

(The rights of patients! Haven't seen that in the Constitution. I believe I have a right to an MRI scan in my living room, and I think Medicare should reimburse my orthopedist to maintain one there in case I ever need it.)

As someone who cares for our State's patients every day, I see first-hand the importance of having modern technology available in our medical practices to timely diagnose and treat patients' injuries and illnesses.

(I also see the importance of being able to reap facility fees from machines that my practice owns and to control how much those machines are utilized. How many other business folks get to play customer and owner at the same time, using taxpayers' and insurance companies' money?)

Continue reading "How to hoodwink legislators into raising health costs" »

Posted by Jay Hancock at 6:09 AM | Permalink | Comments (5)
Categories: Health Care
        

It's not news that the Senate is unlikely to confirm Donald Berwick as head of the Woodlawn-based Centers for Medicare and Medicaid Services. As I wrote last year, "Dr. Donald M. Berwick is far too intelligent, passionate and brutally honest for Congress to approve him to run the bloated Medicare program."

Obama appointed him in recess. What's news, as Robert Pear reports in the NYT, is that Berwick's replacement may end up being his deputy, Marilyn Tavenner, who was head of outpatient services for Hospital Corporation of America, the for-profit hospital chain. Perhaps Tavenner's experience at the cost-obsessed HCA will lead to some real progress on cost and quality in Medicare. But there is ample precedent in government for ex-industry executives to work harder for their former employers than for taxpayers.

Posted by Jay Hancock at 9:49 AM | Permalink | Comments (0)
Categories: Health Care
        

Check out Kaiser Health News' piece on Maryland's system of rewarding hospital quality and penalizing hospital shortcomings. Johns Hopkins Hospital and Howard County General did better than average; St. Joseph Medical Center and University of Maryland Medical Center were among those who did worse. KHN's piece in the Washington Post includes a link to a scorecard for all Maryland hospitals.

The publicity-related incentives here are probably even more powerful than the financial incentives. You don't want your institution on the below-average list for bed sores, infections, accidental punctures etc.

Posted by Jay Hancock at 11:57 AM | Permalink | Comments (1)
Categories: Health Care
        

Maryland Chamber of Commerce President Kathleen Snyder replied to yesterday's column, which portrayed the chamber and other business interests as out to lunch when it comes to fighting against soaring Maryland health costs.

Jay Hancock's recent column ("Maryland business a no-show in fight over the cost of health care," Feb. 22) did not fully describe the efforts of the Maryland Chamber of Commerce and employers in our state to slow the rise of health insurance costs. We have, in fact, already taken positions on 16 health care bills before the Maryland General Assembly and are reviewing more. Our positions are based on our 800 members' needs and interests and determined through rigorous committee processes. With 70 percent of our members having fewer than 100 employees, we are indeed a diverse business organization with a strong track record of success in Annapolis.

Read her whole letter here.

I have only one thing to say in my defense, but it is sufficient: The Maryland Chamber's members include Johns Hopkins Health Systerm, CareFirst BlueCross BlueShield, Patient First and MedStar Health. If you think that with these and many other denizens of the medical-industrial complex as its members the chamber is really an advocate for health-care cost containment, you also think that American Petroleum Institute is fighting hard to prevent climate change.

Posted by Jay Hancock at 11:27 AM | Permalink | Comments (0)
Categories: Health Care
        

Tyler Cowen is getting a ton of attention for his ebook, The Great Stagnation, which argues that the productivity gains reaped by the world for the last century are slowing down, which is very bad news indeed if true. Today on MR he has a good post with lots of links on one striking aspect of the great stagnation -- health care. Basically the great leaps forward with vaccines and pasteurization and antibiotics are behind us, and it's unclear what if any major new advances loom. For all the money we blow on health care, advances in life expectancy are slowing.

James Le Fanu, in his 2000 history of modern medicine, lists definitive moments of modern medicine. In the 1940s there are six such moments, seven moments in the 1950s, six moments in the 1960s, a moment in 1970 and 1971 each, and from 1973-1998, a twenty-five year period, there are only seven moments in total.

For his "Dates of the discovery and sources of the more important antibiotics," the list starts in 1929-1940 with penicillin and ends in...1963, with Gentamicin.

Unstated but suffusing the post is the notion of diminishing returns. Society is spending more and more on health care and getting less and less gain. And because of the unique nature of the product -- information asymmetry, hugely inelastic demand, customers paying with monopoly money from Medicare or insurers -- society doesn't know how to stop throwing money at disease even when the returns get smaller and smaller.

Posted by Jay Hancock at 8:43 AM | Permalink | Comments (5)
Categories: Health Care
        

Nurse Janelle Wissler, blogging on RACmonitor.com, urges hospitals to start the New Year right by not miscoding their insurance claims. Good idea!

New Year's Resolution No. 1: Discard the sports-related mantra that "if you're not cheating, you're not trying hard enough."

Instead, keep in mind that just because you CAN get away with something doesn't mean you should. In 2011, let's try to get it right the first time, every time.

But her online test with coding case studies demonstrates how subtle and complicated the process can be. Example:

A patient is admitted in a hypotensive state. Various causes are considered throughout the stay. Consultations are held with cardiology, neurology, nutrition and internal medicine. Occupational therapy consult is obtained. Medications are adjusted according to the medication reconciliation form, and the patient is told to be cautious in standing from a sitting position. Final diagnosis is "hypotension, multifactorial." Do you query the attending physician to determine what he or she feels is the "most likely" cause, or do you assign "hypotension, NOS," which is the highest weighted MS-DRG assignment of the multiple "possible" causes noted throughout the chart?

Who knows? In patients with multiple symptoms, and especially in patients with multiple diagnoses, it's probably not clear-cut even for professionals.

Posted by Jay Hancock at 6:17 AM | Permalink | Comments (0)
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As noted, my inbox is full of emails from radiologists, patients and a few MRI technicians who wrote in response to this column, "Orthopedist-ownewd MRIs a recipe for soaring costs." But the orthopedists themselves hadn't responded to me. However here is a letter to the editor from Dr. James York. he is an orthopedic surgeon at Chesapeake Orthopaedic & Sports Medicine Center and is head of the group that is trying to get the legislature to nullify a Court of Appeals decision that orthopedist-owned MRIs and CT scanner are illegal.

As a physician who has devoted 25 years to caring for patients in our great state, I was deeply distressed to read Jay Hancock's column attacking the integrity of orthopedic surgeons and other doctors who rely on modern tools such as MRI and CT scans to diagnose patients' injuries and illnesses ("Orthopedist-owned MRIs a recipe for soaring costs," Feb. 9).

Mr. Hancock's claim that orthopedic surgeons drive MRI utilization and cost is contradicted by federal government data showing that more than 80 percent of all advanced imaging services paid by Medicare go to radiologists and free-standing radiology centers, not to orthopedic surgeons and other treating physicians. That same federal data shows that from 1995 to 2005, payments made for advanced imaging services to free-standing radiology centers, commonly owned by the radiologists for whom Mr. Hancock advocates, jumped seven-fold to 23 percent. By contrast, in 2005, orthopedic surgery accounted for only 3 percent of Medicare payments for advanced imaging.

The patient is all but forgotten in Mr. Hancock's attack. Without legislative action,

Continue reading "Orthopedist: Hancock column refuted by data" »

Posted by Jay Hancock at 11:06 AM | Permalink | Comments (1)
Categories: Health Care
        

in today's column. It's hard to argue against Krugman's contention that, measured against the standards of Ron Paul etc., Milton Friedman was a leftist.

Mr. Paul’s subcommittee called three witnesses, one of whom was an odd choice: Thomas DiLorenzo, a professor at Loyola University and a senior fellow at the Ludwig von Mises Institute.

What was odd about that choice? Well, Mr. DiLorenzo hasn’t actually written much about monetary policy, although he has described Fed policy — not just recently, but since the 1960s — as “legalized counterfeiting operations.” His main claim to fame, instead, is as a critic of Lincoln — he’s the author of “Lincoln Unmasked: What You’re Not Supposed to Know About Dishonest Abe” — and as a modern-day secessionist.

No, really: calls for secession run through many of Mr. DiLorenzo’s writings — for example, in his declaration that “healthcare freedom” won’t be restored until “some states begin seceding from the new American fascialistic state.” Raise the rebel flag!

Posted by Jay Hancock at 8:47 AM | Permalink | Comments (8)
Categories: Health Care
        

I got love letters from radiologists yesterday and some pushback from orthopedic patients. Tuesday's column was on the overutilization of MRI machines caused by orthopedists ordering expensive scans on machines they own. Maryland's Court of Appeals ruled last month that the state's law banning medical self-referrals applies to MRI machines and CT machines. Orthopods and others are trying to get the legislature to nullify the decision. Here is some of the feedback:

From a patient:

I understand what you're saying, and it makes perfect sense in many ways.

You obviously haven't had extensive orthopedic problems. As someone who has unfortunately been there, I can attest to the immense aggravation that results from having to reschedule with some facility you've never been to and go through all their hoops. Between the often lengthy delays on the phone to try to make an appointment, the endless questions and sometimes long delays for scheduling, the patient then has to waste another half day driving to the appointment, filling out the never-ending forms and waiting sometimes an hour or more for the brief interaction with the MRI. If you have a job, it's another half day of sick leave. If you need help, it's another imposition on someone else who probably has other things to do.

From a radiologist who sold his practice's imaging center to the local hospital:

You pay the bills for a $1.5mil machine, plus service contract from siemens was $15-20k a month and when we switched to a cheaper service contract siemens refused to send us parts- but they'll sale equipment to Iran and Sadamn Iraq! Plus a tech to run machine at $70-80k a year plus benefits and health insurance, and other expenses. And at $400 a study reimbursement from CMS- started getting difficult to make bills. I saw writing on the walls and that the government wanted us out of business so I pushed to sell to the only potential buyers- the local hospital. So the governments limited wisdom forced us out of business in order to save medical cost, right. Wrong, now the hospital get 2.5 times more than we did from blue cross and the CMS rates are also quiet better than our out patient rates. Cash price for a CT abdomen and pelvis- $4500, we charged about $800. No savings forcing out the little guy!

From a brain-tumor patient:

I was especially interested in your article on MRI's. I have been very upset about Dr's being allowed to own these and a host of other machines and was beginning to think I was the only one! Other countries don't allow that - one reason that heath care elsewhere costs just half of what we spend for health care in the US.

More below the fold:

Continue reading "Docs, patients respond to column on MRI scans" »

Posted by Jay Hancock at 6:00 AM | Permalink | Comments (3)
Categories: Health Care
        

From the FBI on an an alleged $7 million insurance-fraud scheme in Puerto Rico.

After our initial investigative work and the first round of indictments, we were able to identify more than 500 others involved in the same accidental injury scam against the same company. According to the January 2011 indictment, from 2004 to 2008, a doctor from Lares, Puerto Rico falsely completed and signed some of the accidental injury claim forms for policy holders and their dependants—and he pocketed approximately $450,000 for doing it.

How the scheme worked. In general—after word got out that this particular doctor could be bought—policy holders would go to his office claiming every sort of accidental injury imaginable. The doctor, without even examining the patient, would fill out the claim form…for a fee of between $10 to $20 per form.

The policy holders would also make fraudulent claims of accidental injuries on behalf of their kids and other family members...injuries that were never properly verified by the doctor.

Posted by Jay Hancock at 5:11 PM | Permalink | Comments (1)
Categories: Health Care
        

One of the most exasperating arguments made about health reform is: "If we only let the free market work, medicine would get better and less expensive." As Kenneth Arrow showed decades ago, health care is not a free market, hasn't been a free market for 40 years and never will be again.

How can it be a free market when the people making decisions to buy health-care services use OTHER PEOPLE'S MONEY to pay for it? How can it be a free market when the patient "customers" are completely in the dark about what works best for the least money and rely on a priestly class of physicians to decide what is done? The incentives are wrong and the information is wrong.

That's why arguments about "the radiologist monopoly" from orthopedists and others who want to do their own imaging are bogus. Urologists, orthopods and others are acquiring their own CT machines and MRI machines and taking market share from the radiologists. That's a big problem, as today's column notes, because the urologists and the orthopods are the ones ordering the scans. Having their own machines gives them enormous incentives to run up the bill by prescribing unneeded scans, and indeed that's what seems to happen.

In a real market, giving radiologists a monopoly on MRIs would be bad policy. But this isn't a real market. What's desperately needed in American medicine is to separate those prescribing expensive procedures from those profiting from them. Let's use radiologists as expert technicians performing tests ordered by others. That'll cut down on needless, wasteful scans.

Advocates for orthopedists pay lip service to the soaring utilization and cost of MRI scans. A possible bill in the General Assembly allowing orthopods to have MRIs might require the docs to tell patients that other MRI options are available. Come on. Like anybody is going to go to the trouble of signing up with an independent lab when the nice orthopod is right there telling you what to do and the nurse is ready to make the appointment.

Attorney Howard Rubin represents a couple hundred Maryland doctors seeking approval for non-radiologist MRIs who, he says, "are committed to protecting patient choice and access to quality care.” The reason America spends twice as much on medicine as other countries and experiences poorer outcomes is that patients have too much access to care, much of it superfluous, most of it paid for by somebody else, with no regard for the costs. Time to start changing that.

Posted by Jay Hancock at 11:05 AM | Permalink | Comments (19)
Categories: Health Care
        

Get rid of Obamacare. Deregulate medical insurance. Raise the eligibility age for Medicare. But wait! I'm not done. You then repurpose Medicare as catastrophic reinsurance for everybody. That preserves a private market for health insurance and increases individual incentives for cost-saving, taking care of yourself etc. But at a certain level of individual annual medical expense the reinsurance kicks in, keeping the most expensive cases out of the private system.

That makes the private system more affordable while shielding people from the cost of catastrophic illness. (UPDATE: It's also a political compromise between those who want to socialize everythig and those who want to privatize everything. You socialize the catastrophic part with a single payer -- Medicare. You keep the non-Medicaid, noncatastrophic part private.)

This idea is not mine. It's from Kim Meyers via Tyler Cowen on Marginal Revolution:

If in a calendar year a person has in excess of $100,000 in medical expense they are transferred over to Medicare, regardless of age.

The remainder of the citizenry is able to choose from a competitive insurance market, which is essentially selling $100,000 “Term” health insurance policies.

That is from Kim Meyers of Northwestern. As she notes in an email to me, this can be combined with health savings accounts and various kinds of deregulation for the coverage of the lesser expenses. You also can raise the Medicare eligiblity age and I would say you could raise it to a very high level indeed.

Posted by Jay Hancock at 9:11 AM | Permalink | Comments (20)
Categories: Health Care
        

The medical-device industry has a great excuse for having their salesmen and women intrude into the cauterization lab and other clinical settings. These people, who are often paid based on how many products they push, who usually have no formal medical education, are there to train the cardiologists "to make sure" the devices "are being utilized in a safe and effective manner," the Abbott Labs tells Tricia Bishop in today's story.

Thanks, Abbott, but when I'm on the table with a catheter in my chest I'd just as soon leave the treatment to the cardiologist. Selling jet engines to Boeing is an important job, but they don't let the Pratt & Whitney salesmen hang out in the cockpit at 30,000 feet.

Dr. Mark Midei's lawyer defends his close relationship with Abbott by saying it's not unusual in the medical-device business. That's a point in Midei's favor, but it's an indictment of the larger industry.

Posted by Jay Hancock at 9:00 AM | Permalink | Comments (9)
Categories: Health Care
        

According to a complaint filed by the board on August 17, 2010 [1], DeMaio committed a number of standard-of-care violations by placing multiple stents in areas of insignificant or moderate disease; performing multiple angiograms in patients who were asymptomatic and had normal stress tests; unnecessarily implanting an ICD in two patients; failing to adequately inform patients of risks; and failing to obtain informed consent for the off-label use of a device in one patient. In two examples of cases that have made headlines in the Austin American-Statesman, which first reported on the situation, one patient reputedly received more than 30 stents, while another patient—who died—received more than 20.

In his long interview with heartwire, DeMaio took pains to describe the complex cases at the heart of the board complaints. For the patient who died, in whom he'd implanted at least 21 stents and subsequently a defibrillator (DeMaio did fellowships in both EP and interventional cardiology), DeMaio stressed that this was a patient with recurrent ventricular tachycardia postprocedure and that the decision to implant the defibrillator—and ultimately to switch it off—was made with the patient and family's consent and that this is not one of the lawsuits against him. The board complaint, by contrast, says that implantation of the ICD was contraindicated, given the patient's "compromised" condition.

As for the patient who received 32 stents, DeMaio notes that the stents were implanted over successive years, for two acute MIs as well as additional severe blockages treated electively at different times. In this particular case, after having implanted more than 10 stents on two separate occasions, DeMaio scheduled the patient for CABG only to have the patient insist on being taken off the surgery list and demand stents instead.

Posted by Jay Hancock at 5:10 PM | Permalink | Comments (0)
Categories: Health Care
        

Paul Thacker at the Project on Government Oversight, posts on Abbott Laboratories' apparent desire to see me in a cast and on the fabulous barbecue party thrown by Abbott at the house of Dr. Mark Midei.                                                  

As Thacker notes, only the best barbecue would do for the party, which cost Abbott $1,235. Whoever planned the party ordered from Andy Nelson's Southern Pit Barbecue, which the City Paper says "is still the best barbecue in town."

Here is an excerpt of the CP review from last week:

You smell Andy Nelson’s Southern Pit Barbecue before you see it. A whiff of woodsmoke, sweet and lingering, like the smell of burning leaves in the late autumn air, pulls you along York Road to the barbecue joint so familiar that even the big pig on the roof no longer stands out in the commercial landscape. It just belongs there.

Andy Nelson’s has been smoking meats in the neighborhood since 1981, beginning as a seasonal stand at neighboring Valley View Farms and branching out to its current location about 10 years ago. This is more than enough time to cultivate perfection. The spot is habitually voted Best Barbecue by City Paper staff and readers, and Andy Nelson’s name comes up over and over on discussion boards like Chowhound when a Baltimore newbie asks where to find the best barbecue. A recent visit to check up on the small restaurant proves that the folks at Andy Nelson’s are not resting on their laurels (or their woodpile).

Posted by Jay Hancock at 11:54 AM | Permalink | Comments (3)
Categories: Health Care
        

I'm glad to say that nobody has dragged me into an alley and kicked my butt for writing this column on heart stents, as was suggested in an email by a top executive at Abbott Laboratories. (See Tricia Bishop's story in today's paper on the relationship between stent-maker Abbott Labs and Dr. Mark Midei, alleged to have implanted hundreds of unneeded coronary artery stents in patients at St. Joseph Medical Center. More on this in tomorrow's column.)

Bishop reports on findings by an investigation by the Senate Finance Committee, which has oversight over Medicare. The committee subpoenaed records from St. Joseph and from Abbott, who treated Dr. Midei like a celebrity and paid for parties at his house because he installed so many of their stents. But starting in 2013 you won't need a Senate investigation to learn of these deals. The Physician Payments Sunshine Act, part of the health-care reform legislation, requires pharmaceutical companies and medical device makers to disclose payments to docs to the government, which will make them public.

Vermont and other states have already started requiring this kind of disclosure. The embarrassment factor appears to have diminished the gravy flowing from the medical industry to the medical caregivers. Here's a good piece from Kaiser Health News:

The overall dollar value of gifts to Vermont physicians "has been going down steadily for the last three years," says Wendy Morgan, chief of the state attorney general's public protection division. "I think there are more health care providers who won’t accept gifts."

Vermont lawmakers want to make sure of that. Last year they amended the law to ban most gifts outright, including food, which accounted for $800,000 of the 2009 total.

The other states with similar legislation, Massachusetts and Minnesota, have also outlawed many forms of corporate gift-giving, although they do allow doctors to accept speaking fees and most product samples. All three states allow research grants.

Posted by Jay Hancock at 6:01 AM | Permalink | Comments (6)
Categories: Health Care
        

John-John Williams has a piece in today's paper on the arms race among Baltimore hospitals to offer patients the most luxury.

Hospitals are vying for patients through upscale services, including complimentary valet parking, house musicians and round-the-clock room-service meals. In the Baltimore region, where top-rated hospitals abound, the competition can be fierce, and these added perks can tip the scales for potential patients.

OK, there is a quality-of-care argument to be made for private rooms. Patients without roommates tend to catch fewer bugs from other patients. And 32-inch flat-screen TVs in every room will not by themselves break the back of the national economy. But attempts to make hospitals look like the Grand Hyatt betray wider flaws in the health-care system.

Patients love these upgrades in the same way that they love the latest and most in operations and tests. And why not? Even though many of these items may contribute little or nothing to improving patient health, patients for the most part don't have to worry about the extra cost -- at least not directly. So why not demand the in-house harpists and palatial lobbies? It's not your money -- until your insurance premiums and federal taxes get raised to pay for it all.

Posted by Jay Hancock at 10:19 AM | Permalink | Comments (7)
Categories: Health Care
        

Some values are universal. Among them are love, patriotism and the occassional willingness to accept bribes for medical care referrals. Two weeks ago St. Joseph Medical Center settled allegations that it paid kickbacks to cardiologists to send patients its way.

Yesterday there was a similar story in China Daily. Doctors at a hospital in Hangzhou, where we're flying tomorrow, are alleged to have taken cash, gift cards and digital cameras in return for prescribing products made the by Hangzhou Tairui Medical Device Co. The story, which seems to be based on an anonymous Internet post, is quite thinly sourced. But China's efforts to crack down on doc kickbacks suggests that the practice is widespread.

And the same ingredients for potential medical bribes exist here as they do in America: Customers who rely on third parties not only to select the product but also to pay for it to; and a medical class whose income often depends as much on prescribing products and procedures as it does on keeping patients healthy.

Posted by Jay Hancock at 4:53 AM | Permalink | Comments (0)
Categories: China, Health Care
        

How did St. Joseph Medical Center get to be one of the highest-volume heart-stent operations in the state? Well, according to federal allegations in a settlement announced today by U.S. Attorney Rod Rosenstein, St. Joseph paid doctors to send patients its way. Or, in the language of the settlement, St. Joseph gave MidAtlantic Cardiovascular Associates "remuneration in excess of fair market value... in exchange for the referral of lucrative cardiac procedures..."

Kickbacks, in other words. "Kickbacks give doctors an incentive to pursue unnecessary treatments...," Rosenstein says in the press release. St. Joseph does not admit liability or wrongdoing in the settlement. But it nevertheless agreed to pay $22 million to settle the claims. Everybody knew this case was out there, but it took years to settle. That's likely because new allegations have emerged that St. Joseph's Dr. Mark Midei (formerly with MidAtlantic) implanted hundreds of unnecessary coronary artery stents.

The whistleblowers in the case were Garth McDonald and other docs at Cardiac Surgery Associates, competitors of MidAtlantic, according to the settlement. Friction between the practices goes way back and was beautifully chronicled by Geeta Anand and Ron Winslow in a 2003 Wall Street Journal piece. Here's how it begins:

TOWSON, Md. -- During the late 1990s, Garth McDonald's group of eight heart surgeons was busy and thriving. They performed about 110 operations a month at St. Joseph Medical Center, and senior partners each earned more than $1 million a year.

By September 2000, the caseload at Cardiac Surgery Associates had fallen by nearly two-thirds to just 40 surgeries a month. In August of this year, it was down to 25.
Behind that drop is a heated dispute between two groups of doctors that used to work closely together but now have been pushed apart by big changes in the economics and science of medicine. Dr. McDonald's surgeons rebuffed an offer to merge with a big group of cardiologists, who treat heart patients and make referrals for surgery.
So the cardiologists hired their own surgeons and referred patients to them instead. Now the fight has erupted into a lawsuit, with Dr. McDonald's group accusing the cardiologists of trying to drive them out of business.

The bitter dispute has upended longstanding relationships in and around this Baltimore suburb.

Posted by Jay Hancock at 6:33 PM | Permalink | Comments (1)
Categories: Health Care
        

The must-read story of the day is Scott Calvert's piece on Baltimore Behavioral Health, a addiction-treatment nonprofit that somehow finds (and bills for) a diagnosis of patient mental illness at almost three times the average rate of all Maryland clinics treating drug abuse.

This is a state program. Almost all BBH's money comes from Medicaid -- $16.7 million for the most-recent fiscal year. Less than $50,000 came from private patient payments, the organization's tax forms show. So why did it take The Baltimore Sun to bring the irregularities to light? There are red flags that should have prompted state authorities to take a look: the high salaries and large raises top executives made in recent years; the (astonishing) lack of audited financial statements; the sharp increase in billings; the domination of the board of directors by insiders making the money.

Not to mention the anomalies in the clinical data. As Calvert reports, about 90 percent of BBH's patients were deemed to be dual-diagnosis -- to have depression or bipolar disorder in addition to drug addiction. But statewide only 31 percent of patients in addiction-treatment centers are also diagnosed with mental illness.

Posted by Jay Hancock at 10:16 AM | Permalink | Comments (3)
Categories: Health Care
        

Everybody is trying to knock down Janet Ademy's story in the Wall Street Journal on McDonald's health plan. The fast-food chain told HHS that it might have to drop its "mini-med" plan for thousands of workers because of requirements in the new health-care law.

McDonald's and the Obama administration took issue with the accuracy of a published report on the dispute Thursday, saying the restaurant chain has no plans to drop health coverage for employees. But McDonald's said it may have to replace its plan with another form of insurance.

But there's nothing wrong with the WSJ story. It quotes a letter McDonald's sent to HHS saying it might scrap the plan.

"Having to drop our current mini-med offering would represent a huge disruption to our 29,500 participants," said McDonald's memo, which was reviewed by The Wall Street Journal. "It would deny our people this current benefit that positively impacts their lives and protects their health—and would leave many without an affordable, comparably designed alternative until 2014."

McDonald's won't have to drop the plan. It'll get an exemption. But the story shows what happens with such complex legislation and the jerry-rigged health system we have built for ourselves. Dare I say -- Universal health care would have been a lot simpler (and cheaper) with a single-payer system instead of the crazy quilt of employer sponsors and private-insurance carriers that we have.

Posted by Jay Hancock at 8:53 AM | Permalink | Comments (13)
Categories: Health Care
        

Sunday's column is about what state and national authorities are doing, if anything, about the risk that, to crank up hospital profits, in an almost total absence of controls, interventional cardiologists are installing coronary-artery stents in unblocked arteries.

Here are other columns from this year on stents:

Heart stents cost billions, may offer little benefit

St. Joseph stent case could be one of many, doctor says

State should press inquiry into needless stents

St. Joseph must pay victims to close stent case

Posted by Jay Hancock at 11:32 AM | Permalink | Comments (2)
Categories: Health Care
        

From the NYT story on Avandia:

From now on, drug regulatory authorities are unlikely to approve medicines simply because they help diabetics control blood sugar levels — the standard for more than 80 years. Instead, authorities are likely to insist that companies prove that their medicines improve the quality or length of diabetics’ lives.

The Avandia story also marks a new and unsettling period for pharmaceutical companies because Avandia’s risks became known only after Dr. Nissen analyzed data from myriad trials that GlaxoSmithKline had been forced to post on its Web site as a result of a legal settlement. Such public postings are increasingly the norm, which means that drug makers can no longer easily hide or control scientific information about their medicines.

Posted by Jay Hancock at 4:09 PM | Permalink | Comments (1)
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To partly paraphrase the former New England Journal of Medicine editor quoted in this NYT piece, these results are shocking and totally unsurprising. Doctors getting paid millions by companies that make knee and hip replacements and other medical devices are doing "research," publishing it in medical journals and then failing to disclose the payments as a conflict of interest.

The study, done by the Archives of Internal Medicine, wasn't a perfect exemplar of transparency, either. Observing a quaint, clubby protocol of academia, it failed to disclose the identities of the doctors raking it in.

Twenty-five out of 32 highly paid consultants to medical device companies in 2007, or their publishers, failed to reveal the financial connections in journal articles the following year, according to a study released on Monday.

The study was based on disclosures by five medical device companies, mostly forced by government investigations. The companies paid about $250 million to consultants in 2007, including royalties, the study says. Zimmer paid $87 million; DePuy Orthopaedics, $63 million; Stryker, $45 million; Biomet, $27 million; and Smith & Nephew, $24 million.

Of that total, $114 million went to 41 doctors, the study said, of whom 32 wrote or were co-authors on orthopedic journal articles the next year.

Posted by Jay Hancock at 8:42 AM | Permalink | Comments (0)
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It is possible to argue about whether an artery that is 40 percent blocked by plaque needs a stent. The medical consensus is that it does not, but presuambly clincians can have a debate. What you can't do is stent an insignificantly blocked artery and then tell Medicare it was 80 percent or 90 percent, as McLean is alleged to have done. If the allegations are true, they amount to defrauding Medicare and are one reason health costs are so high.

On or about September 8, 2005, in the District of Maryland, the defendant, JOHN R. MCLEAN, in a matter involving a health care benefit program, did knowingly and willfully make a materially false, fictitious and fraudulent statement and representation, and make and use any materially false writing and document knowing the same to contain any materially false, fictitious, and fraudulent statement and entry, in connection with the delivery of and payment for health care benefits, items and services; that is, defendant MCLEAN caused an entry in the Medical Record of Patient HK to state that the lesion in Patient HK’s LAD was 80 percent, well knowing that the Medical Record contained a materially false, fictitious and fraudulent statement and entry, in that the lesion was substantially less than 80 percent.

On or about November 2, 2005, in the District of Maryland, the defendant, JOHN R. MCLEAN, in a matter involving a health care benefit program, did knowingly and willfully make a materially false, fictitious and fraudulent statement and representation, and make and use any materially false writing and document knowing the same to contain any materially false, fictitious, and fraudulent statement and entry, in connection with the delivery of and payment for health care benefits, items and services; that is, defendant MCLEAN caused an entry in the Medical Record of Patient WF to state that the lesion in Patient WF’s LAD was 80 to 90 percent, well knowing that the Medical Record contained a materially false, fictitious and fraudulent statement and entry, in that the lesion was substantially less than 80 to 90 percent.

Continue reading "What the indicment says McLean did wrong " »

Posted by Jay Hancock at 12:20 PM | Permalink | Comments (1)
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Read the entire New Yorker essay by Atul Gawande on medical decisions made in the last months of life, which are responsible for an enormous portion of Medicare expense. It's a moving explantion of why our reluctance to confront death proves so expensive for society.

A study led by the Harvard researcher Nicholas Christakis asked the doctors of almost five hundred terminally ill patients to estimate how long they thought their patient would survive, and then followed the patients. Sixty-three per cent of doctors overestimated survival time. Just seventeen per cent underestimated it. The average estimate was five hundred and thirty per cent too high. And, the better the doctors knew their patients, the more likely they were to err.

Second, we often avoid voicing even these sentiments. Studies find that although doctors usually tell patients when a cancer is not curable, most are reluctant to give a specific prognosis, even when pressed. More than forty per cent of oncologists report offering treatments that they believe are unlikely to work. In an era in which the relationship between patient and doctor is increasingly miscast in retail terms—“the customer is always right”—doctors are especially hesitant to trample on a patient’s expectations. You worry far more about being overly pessimistic than you do about being overly optimistic. And talking about dying is enormously fraught

The idea that "the customer is always right" can prove especially expensive when the customer is spending somebody else's (ie., the taxpayer's, via Medicare) money, carte blanche.

Posted by Jay Hancock at 6:34 AM | Permalink | Comments (4)
Categories: Health Care
        

I'll be on the Rodricks show today on WYPR (88.1 FM) with Robert Murray of the Health Services Cost Review Commission and Carmela Coyle of the Maryland Hospital Association. We'll be talking about this column, which said:

In the worst economy in decades, as companies and families downsize and economize, one Maryland industry wants to keep doing business like it's 2007. And it wants you to foot the bill.

The Maryland Hospital Association disliked the raise it got this month from regulators...

Ladies and gents, see the Eighth Wonder of the World: An industry that wants immunity from cost-cutting.

Posted by Jay Hancock at 10:42 AM | Permalink | Comments (0)
Categories: Health Care
        

Yes, the state could save some $829 million from federal health reform over the next decade, as Andrea Walker reports today. That's largely because new batches of federal money are coming in to pay for Marylanders' care. But starting in 2020 the savings begin shrinking, says the Hilltop Institute, which wrote the report analyzing savings.

The problem is that, even as money gets shifted into Maryland from Washington, overall health costs will continue soaring and soaring. Some may use the Hilltop report to suggest that Maryland can relax in its efforts to control medical costs. Says Hilltop:

This favorable forecast, however, must not be permitted to weaken the state’s commitment to reduce the overall cost of health care. First, net savings begin to decline toward the end of the decade, as PPACA shifts a greater share of the financial responsibility for Medicaid Expansion to the states. Second, our health care system will soon be unsustainable, regardless of these savings, unless we succeed in improving quality while reining in the runaway growth in costs. Thus, in addition to realizing the projected savings, the state must reaffirm and strengthen its commitment to immediately begin serious and sustained efforts to bend the cost curve and align incentives toward quality, safety, and efficiency.

Posted by Jay Hancock at 9:22 AM | Permalink | Comments (4)
Categories: Health Care
        

Sunday's column was on the complaints being made by hospitals because they're getting a guaranteed revenue increase at a time when many businesses are seeing revenue and price plunges.

The upshot was: They haven't done enough to cut costs and should stop complaining. Got lots of responses, including this good one from a registered nurse. Agree with many of her points, but there are many ways hospitals can cut costs without cutting back on nurses and quality of care: Close and consolidate hospitals; cut management padding; stop spending millions to subsidize doctors -- and that's just in overhead. Hospitals and doctors also prescribe and perform far too many unnecessary procedures.

Jay: I read your article in the Balt. Sun printed on 7/18 with some skepticism. The article drew my attention as I am a Registered Nurse who celebrated 29 years of nursing this last June. I was a nurse before Managed Care came on the scene. You need to interview the working people who are involved in acute care. Although most of my nursing experience has been in acute care, I left that environment in 2008 and vowed to never return. Any professional who has been in the acute care environment within the last 10 years will inform you that cutting costs is much easier said than done.

Continue reading "Nurse: Hospital cost-cutting hurts care" »

Posted by Jay Hancock at 10:33 AM | Permalink | Comments (0)
Categories: Health Care
        

Lots of reaction to Sunday's column on Dr. Donald Berwick, the self-described "radicalized" doctor appointed by Obama to take over Medicare and Medicaid. I'll respond to some of the objections.

This will lead to socialized medicine.

Medicine is already socialized. Get used to it. Private insurance is the socialization of risk with a corporate fig leaf. Nobody pays for health care the way they pay for cars and coffee.

But I paid my fair share into Medicare. I deserve whatever care my doctor wants to give me even if the cost far outweighs the benefits.

Sorry, but one serious illness usually wipes out what anybody paid into Medicare over their career. Medicare is spending hugely more than it takes in. That's the problem.

If only we could stop giving money to people on welfare with seven kids and no jobs, we could keep paying for Medicare for responsible people like me.

A safety net for the poor is an integral part of a rich, modern society, but leave that aside. There's not enough money there to pay for Medicare. Medicare is so huge and threatening that it overwhelms and renders irrelevant other social programs except Social Security, which isn't in nearly as much trouble. You could pay for Medicare growth by sharply cutting defense spending, but I hear that argument much more rarely.

We can fix health care by privatizing it. Just end all the government programs and give people tax credits to buy health insurance.

Besides the moral problems -- extreme privatization would leave millions uninsured in the richest country in the world -- privatization will wouldn't stop extreme medical inflation. Economist Kenneth Arrow showed years ago that health care isn't like any other product and defies attempts to treat it like coffee and cars. There's a knowledge problem. Patients can't intelligently buy health services that they don't have the training to understand. There's an agency problem. The decisions on what to buy are made by one third party -- the doctor -- and paid for by another third party -- the insurance company. And demand for health care is extremely inelastic. We want more more more, especially when somebody else is paying.

Free markets are wonderful. They have brought millions of humans out of poverty. But there are large problems when applying markets to 21st century health care.

Posted by Jay Hancock at 8:38 AM | Permalink | Comments (17)
Categories: Health Care
        

This is scary:

If you were going to live to be 100, would you want to know it?

When it becomes affordable to have one’s genome sequenced, perhaps in the next few years, a longevity test, though not a foolproof one, may be feasible, if a new claim holds up. Scientists studying the genomes of centenarians in New England say they have identified a set of genetic variants that predicts extreme longevity with 77 percent accuracy.

If we can identify the genes determining that we'll live to 100, soon we'll identify the genes that determine we die at 55. That's more knowledge than perhaps we need. It's certainly more knowledge than our insurance companies ought to have.

Posted by Jay Hancock at 3:47 PM | Permalink | Comments (1)
Categories: Health Care
        

The piece by Fitzhugh Mullan et. al. in the newest Annals of Internal Medicine focuses on the role medical schools play in producing primary-care doctors. It ranks schools in terms of how they fulfill their "social mission" of educating primary-care docs to be the first medical responders for sick people and the consultants to keep healthy people healthy. Meredith Cohn and Andrea Walker write about the study in today's paper. But the schools aren't the important variable in the equation, and the family-doc shortage isn't mainly their fault.

True, there are steps places such as Johns Hopkins could take to boost production of primary-care physicians. Direct tons of financial aid to students studying internal medicine, for example. The main factor preventing more people from becoming primary-care doctors, however, is the abysmally low pay that these kinds of practitioners receive. Studentdoc.com tells the story. Family-care doctors make as little as $128,000 a year. Average pay is $204,000. Average pay for pediatricians is $175,000.

That might sound like a lot of money to many people, but for highly trained doctors charged with keeping people healthy, it's not nearly enough. Medicare and private insurers need to reduce payments for specialists and "procedure medicine" and start paying more to docs who stop sickness before it happens. Those docs are the primary-care folks.

Posted by Jay Hancock at 8:34 AM | Permalink | Comments (9)
Categories: Health Care
        

Tricia Bishop reports that Dr. Mark Midei, alleged by St. Joseph Hospital to have implanted more than 500 coronary-artery stents that may have been unneeded, is now charged by the Maryland Board of Physicians as follows: "Willfully makes or files a false report or record in the practice of medicine" and "Grossly overutilizes health care services." The proceedings could lead to the loss of his license.

A couple aspects of the story are noteworthy:

-- The board received its initial complaint about Midei in November 2008. An anonymous person describing him/herself as a St. Joseph employee detailed 36 cases in which stents had supposedly been improperly placed. The board received another, similar complaint in April 2009. But it didn't launch the investigation until it was notified on July 19, 2009, that St. Joseph had revoked Midei's privileges.

-- The board charging document includes the first bits of explanation from Midei to be made public. To wit:

Midei explained the discrepancy by saying he routinely used certain percentages — 70, 80, 90 -- as shorthand to signify mild, moderate or significant blockage, the document claims. But he conceded, after reviewing his cases, that there was "significantly lower percentages of stenosis than he had initially dictated at the time of the procedure."

Midei also told hospital staff that he considered other clinical symptoms aside from test results when determining whether to place a stent, according to the charging document.

When queried by St. Joseph officials about the stents, according to the charging document, Midei "expressed 'a little bit of surprise' that he had an established pattern of overestimating the degree of stenosis by consistently using the default percentages."

Posted by Jay Hancock at 1:41 PM | Permalink | Comments (1)
Categories: Health Care
        

One of the unanswered questions in the case of Dr. Mark Midei and St. Joseph Medical Center, in which Midei is alleged to have placed more than 500 coronary artery stents in patients who may not have needed them, is: Who initially called attention to Midei?

So far the hospital has said only that it received a complaint from a patient. In gathering documents for a column on stents for this Sunday's paper, however, I received a state report that says the complaint came from "a patient who was also employed by the hospital, which prompted the hospital to initiate a review..."

So the patient was also a St. Joe employee. The way compliance and quality-assurance were set up at St. Joe, maybe the only people who could have been alert to unneeded stents were insiders. Before the hospital made reforms, there was a lack of accountability in its official procedures, at least in terms of identifying successfully implanted but unnecessary hardware. Certainly the patients never could have figured out they had unneeded stents, if that's what happened. (The story hasn't been fully told, and Midei has said he expects to be exonerated.) But docs and hospital officials have told me that, generally in catheterization labs, techs and nurses are often in a position to see the angiogram results and interpret them. And they talk to other employees. (St. Joe hasn't identified the employee/patient who complained about Midei.)

The lack of safeguards against unnecessary implants seems to be widespread. To get a good sense of how inadequate hospital protocols are at catching potential unnecessary stents, check out this post from Wachter's World, the blog of Dr. Bob Wachter, the chief of medicine at the University of California San Francisco Medical Center, in which he ruminates on the St. Joe situation.

I quoted Wachter in this March column on likelihood of stent abuse at other hospitals. I'm the "Baltimore reporter," mentioned in his post, who asked him the question that he says "threw me back on my heels."

Posted by Jay Hancock at 6:00 AM | Permalink | Comments (1)
Categories: Health Care
        

Good piece by Steve Lohr in NYT on a study illuminating the crisis in primary-care medicine. In a nutshell, the compensation system for family doctors is broken. They ought to be paid and paid handsomely for preventing illness. Instead they're paid a pittance (relative to their expertise) that is tied to visits from sick patients. And much of their work is for free.

Family doctors are paid mainly for each visit by patients to their offices, typically about $70 a visit. In the practice in Philadelphia covered by the study, each full-time doctor had an average of 18 patient visits a day.

But each doctor also made 24 telephone calls a day to patients, specialists and others. And every day, each doctor wrote 12 drug prescriptions, read 20 laboratory reports, examined 14 consultation reports from specialists, reviewed 11 X-ray and other imaging reports, and wrote and sent 17 e-mail messages interpreting test results, consulting with other doctors or advising patients.

Posted by Jay Hancock at 6:05 AM | Permalink | Comments (1)
Categories: Health Care
        

Nurses are probably already the hardest working people in health care. Nurse practitioners -- highly trained professionals who increasingly function as doctor proxies -- are surely going to be part of the solution to the health care crisis. Especially if pay for primary-care doctors continues to lag that of specialists. In 2008 median primary-care doc pay was $186,000, according to the American Medical Association. Some primary care docs make much less and have hundreds of thousands of dollars in student loans to pay off. So fewer and fewer med school students are going into primary care, even though primary care docs -- who keep people well instead of treating people after they get sick and charging for procedures -- are what the system needs.

Nurse practitioner pay, at a median of $83,000, according to salary wizard, is approaching that of primary-care docs.

It's nice that the General Assembly cut the paperwork needed to become a nurse practitioner. But it will do little to increase medical expertise where it's needed. The legislature should have allowed nurse practitioners to eliminate ties to doctors altogether and practice on their own. But it caved to pressure from Med Chi, the Maryland doctor trade group concerned to preserve the monopoly of licensed physicians. Washington, Oregon, Alaska and seven other mostly Western states (rural states where docs in the backcountry are scarce) already allow independent N.P. practice. So does the District of Columbia.

Posted by Jay Hancock at 9:14 AM | Permalink | Comments (26)
Categories: Health Care
        

Much hot air has been blown about the tyranny that will ensue once the Internal Revenue Service starts enforcing the requirement in Obamacare for almost everybody to have health insurance coverage. Republicans hallucinated about the "15,000" IRS agents that would enforce the law. People went on about "brownshirts" etc. Actually, the enforcement provisions look too weak. The only way this plan is going to work is if young people sign up to subsidize the older and sicker. But the risks of not buying health insurance look minimal.

First, the penalties to be assessed are probably far less than what coverage will cost. Second, it looks like the IRS is not exactly going to be keeping a hawk eye. This accounting blog says it'll basically be an honor system. Libertarians (!!) Megan McArdle and Tyler Cowen suggest the mandate is too weak.

Here is a description of the penalties from the Joint Committee on Taxation:

The penalty is assessed through the Code and accounted for as an additional amount of Federal tax owed. However, it is not subject to the enforcement provisions of subtitle F of the Code. The use of liens and seizures otherwise authorized for collection of taxes does not apply to the collection of this penalty. Non-compliance with the personal responsibility requirement to have health coverage is not subject to criminal or civil penalties under the Code and interest does not accrue for failure to pay such assessments in a timely manner.

Posted by Jay Hancock at 8:53 AM | Permalink | Comments (4)
Categories: Health Care
        

This week's Economist magazine (pro-markets, thought Bill Clinton should resign for lying about Monica Lewinsky) gets the historic health bill right. The magazine says:

... It is wrong for a country as rich as America to have tens of millions of people without health insurance. Beyond them is the much larger number of people who fear falling into that position through losing their jobs; and the larger number again who cannot get affordable insurance because they have an existing medical condition, or because they are too old, or because they have exhausted the "lifetime caps" imposed by insurance companies. The health-reform plan represents the last chance, perhaps for decades, of erasing one of the least creditable differences between America and the rest of the industrialized world. If this president, who came into office with solid congressional majorities and stratospheric ratings fails, neither he nor his successors will dare touch health care for many years to come; and that would be a tragedy.

Now that the United States has joined the civilized world in trying to provide universal medical coverage, maybe it can start concentrating on controlling costs. An OECD study last year showed that the U.S. spent 16 percent of its economic output on health care in 2007, half again as much as the nearest runner-up and nearly twice what the average developed country spends. France, Switzerland and Germany, numbers 2, 3 and 4, were 10 percent or 11 percent.

There's no financial reason the U.S. can't continue delivering decent care while controlling costs. The trick will be getting the health-care system to change its behavior. The cost "controls" in the health-care bill just passed are "top down" -- basically statements or goals of what aggregate spending will do in coming years. But real change won't come until we work on the "bottom up" details of doing fewer unnecessary procedures and paying doctors to keep patients well instead of to perform tests and surgeries after they get sick.

Posted by Jay Hancock at 9:10 AM | Permalink | Comments (22)
Categories: Health Care
        

An NIH-convened panel concludes that most women don't need repeat C-sections if they're already had one, Kelly Brewington reports in today's Sun. The medical assumption that vaginal birth is dangerous for women who've given birth previously by C-section has helped drive the huge increase in C-section deliveries -- along with fear of malpractice lawsuits. About one birth in three in the United States is by C-section.

Fewer C-sections wouldn't just mean quicker recoveries for moms or a reduction in C-section-associated complications. As a reader recently pointed out, it would mean billions in savings for the health-care economy. A normal vaginal birth costs about $6,000, according to figures from a few years ago. A normal C-section is twice that. With 4 million annual live births, that's at least $7 billion a year that C-sections are costing Americans.

Posted by Jay Hancock at 8:40 AM | Permalink | Comments (5)
Categories: Health Care
        

Of the many unanswered questions about allegations of unneeded stent implants at St. Joseph Medical Center is this one: If the allegations are true, will somebody stand to collect a reward under the federal False Claims Act? The False Claims Act allows citizens to sue federal contractors (in health care it's usually Medicare providers) on behalf of the government and share up to 25 percent of any reward. Christopher Mallavarapu, the cardiologist I wrote about on Sunday, was the official whistleblower in a case of unneeded stents in Louisiana.

St. Joseph has said that it began investigating stent histories after a patient complaint and a federal investigation simultaneously raised questions. Last week I asked whether to the hospital's knowledge there is a would-be False Claims Act plaintiff who tipped off authorities. This is the response of spokeswoman Vivienne Stearns-Elliot:

"St. Joseph Medical Center cannot speculate whether or not there is a whistleblower in this matter. Our concern is not how this investigation began, but rather the steps we have taken and continue to take to address the substantive issues and to move forward."

Posted by Jay Hancock at 6:24 AM | Permalink | Comments (4)
Categories: Health Care
        

Sarah Palin's provocative reference to "death panels" last summer prompted paranoid fantasies about government health care and more excuses to delay the screaming need to control health costs. The Philadelphia Inquirer did what newspapers are supposed to do: It embedded itself on what some might imagine to be a death panel and wrote in great detail about what happened.

Reporter Michael Vitez spent months with a "palliative care" team at Abington Memorial Hospital and the Tole family as they agonized over what to do about 74-year-old Mary Tole, a mother, sister and grandmother who had fallen into sudden, mysterious and what seemed to be permanent dementia and decline. The family and health professionals allowed Vitez to be in the room as they made the tough decisions on whether to continue the administration of phenomenally expensive care for Mary Tole.

Yes, Vitez's presence probably subtly changed the story. The act of observing always alters what is observed, whether in quantum physics or journalism. Would people have acted differently had the reporter not been there? But the piece is an amazing, sensitive and complete picture of the terrible choices that must be made. I say "complete" because it contains what these kinds of stories almost never do -- the cost of the care. Treating Mary Tole cost Medicare and taxpayers more than $700,000. If you don't include the dollars, you haven't told the whole story.

Mary Tole's family, like most Americans, had no idea what a palliative care team was, or what the meeting would be about. The family had heard the noise all summer in the media over "death panels" and "pulling the plug on Grandma."

Was that what this was?

Continue reading "An extraordinary look inside a 'death panel' " »

Posted by Jay Hancock at 8:39 AM | Permalink | Comments (3)
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The county-by-county health study reported by Meredith Cohn and Larry Carson includes many variables derived from data collected by the Centers for Disease Control. These include premature death, binge drinking, obesity, low birth weight etc. The conclusion, as they note, is no surprise. On average, people who live in well-off suburbs are healthier than folks in rural counties or Baltimore city.

Howard County is healthiest, Montgomery County No. 2, Frederick County No. 3. Least healthy is Baltimore, followed by Somerset and Dorchester counties. Click here for an interactive map and ranking of Maryland counties by health.

But the results would have been very similar if the surveyors had looked at one variable only: smoking. Somerset County is No. 1 in smoking -- 33 percent of adults vs. 11 percent in Montgomery County. In Baltimore 26 percent of the adults smoke. Other top smoking counties are Cecil, Caroline, Dorchester and Allegheny. Not only is smoking deadly. It's also strongly associated with other unhealthy behavior. Click here for an interactive map and ranking of Maryland jurisdictions by smoking.

Posted by Jay Hancock at 8:52 AM | Permalink | Comments (0)
Categories: Health Care
        

Holy cow. As Noam Levey reports in today's Baltimore Sun, federal bean counters estimate that health care comprised 17.3 percent of the economy last year. That's the highest portion ever. Also, last year health spending jumped higher in one year as a portion of the economy than ever before in the half-century statisticians have been keeping track. You can see the trend in metro Baltimore, where health-care has accounted for maybe half of all the jobs created in the last five years.

The Woodlawn-based Centers for Medicare and Medicaid services report that government-financed health care could surpass privately-paid health care this year for the first time. That's 6 years sooner than had previously been estimated. The recession is a driving factor in these trends. The non-health-care portion of the economy was stagnant last year, which would give health care a bigger portion even if it grew at a normal rate. But the recession caused many to lose their private health insurance and go on Medicaid, the health program for low-income folks.

It's a total mess. It can't continue. Congress needs to do something.

Posted by Jay Hancock at 8:41 AM | Permalink | Comments (7)
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Big pharma concern AstraZeneca announced more major job cuts and restructuring this morning, but it could be good news for the company's MedImmune division, based in Gaithersburg. While the company plans to shrink as a whole, including in research & development, it sounds like AstraZeneca is bringing additional jobs to MedImmune. Overall the company anticipates a net decrease of 1,800 jobs. But the press release also refers to "further expansion of our Biologics activities." That's MedImmune. From the press release:

These initiatives are designed to achieve material efficiency savings in R&D, which will partially mitigate the increase in R&D investment that would be required as projects in the current pipeline progress to the more resource intensive, later phases of development. By 2014, annual savings of $1 billion should be realised, of which one-half is estimated to be cost savings and the other half cost avoidance. Based on preliminary estimates, approximately 3,500 positions may be affected by this programme. After taking account of positions that will be retained whilst being relocated to another site, the investment in new skills and capabilities and further expansion of our Biologics activities, the net reduction may be around 1,800 positions.

Posted by Jay Hancock at 9:17 AM | Permalink | Comments (1)
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Kelly Brewington has a good piece in today's paper on stents for coronary arteries. Stents have been in the news because the leadership at St. Joseph Medical Center send letters to hundreds of patients indicating they may have received unneeded stents from Dr. Mark Midei. These patients got stents when their arteries weren't significantly blocked, the hospital says. The implication, of course, is that the hype surrounding stents and the inducements of handsome reimbursement impelled St. Joseph and Midei to install more than were needed.

But as Brewington notes, unless a patient is in the middle of a heart attack, implanting a stent is a tough call even if arteries are substantially blocked. The key info is from Dr. Mark Hlatky at Stanford, a professor of cardiovascular medicine at Stanford University.

[For stable patients,] stents only relieve symptoms; they don't make you live longer, Hlatky said, adding that he falls on the conservative side of the debate. The first question any physician and patient should ask is if interventions are needed at all or whether a person's symptoms could be helped with drugs alone, he said.

And some doctors argue that they don't even relieve symptoms -- the chest pain of angina -- for very long. A landmark was the 2007 publication of the COURAGE study, which showed that stenting DID NOT REDUCE HEART ATTACKS even in patients with substantially blocked vessels. So why is the system spending billions of dollars on stents? Here is last week's column on St. Joseph and stents, which said:

Don't let the situation at St. Joseph, where patients received stents when they might have had only slightly blocked arteries, obscure the big picture. Most people getting stents don't need them even if scans show substantial blockage, studies suggest. Stents can be dangerous, too.

Posted by Jay Hancock at 9:13 AM | Permalink | Comments (3)
Categories: Health Care
        

So to get health reform passed before Scott Brown is seated as the junior senator from Massachusetts, it looks like the House might pass Senate bill unchanged. Democrats from both chambers have been negotiating behind the scenes for weeks, and the dickering could have made the final bill better -- especially in terms of cost control.

But the need for speed makes it probable that the Senate bill will be the final bill -- if there's any final bill at all. Unlike the House bill, the Senate bill contains no public option. Neither does the Senate bill finance new coverage with a surtax on the wealthy the way the House measure does. Instead it slaps an excise tax on so-called Cadillac health insurance plans. Meanwhile Virginia Democrat Sen. Jim Webb has called for a suspension on all health care votes until Brown is seated.

Posted by Jay Hancock at 10:18 PM | Permalink | Comments (6)
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Last week The Sun broke the story that St. Joseph's Medical Center in Towson had alerted hundreds of patients that they may have received artery-clearing stents they didn't need.

Already the malpractice lawyers are out in force. Saiontz & Kirk was running TV ads over the weekend and they've already got a toll-free number. 1-888-STENT-11! The usual somber-voiced voiceover guy comes on. "ATTENTION! St. Joseph's hospital stent patients. If you or a family member received a warning letter from St. Joseph's Medical Center in Towson, Md., about medical concerns regarding a stent procedure YOU have important legal rights."

Belsky, Weinberg & Horowitz have a Google paid link: Improper Stent-Dr. Midei? "You've Been Wronged. We Can Help Protect Your Legal Rights!" Their Web page says: "A former cardiologist with a large, well-known Cardiovascular Group in Baltimore is under investigation for performing unneeded and unnecessary stenting procedures upon patients who did not clinically require stenting based on test results." Amazing how they know the stents were unnecessary even though the the investigation is still continuing, no evidence has been entered in court and Dr. Mark Midei, who says he expects to be exonerated, hasn't had a chance to give his side of what happened.

With so much money on the line and several lawyers vying for would-be plaintiffs' business, fundamental economic theory says that plaintiffs should be able to bargain the lawyers down from their usual 30 percent fees or whatever they are. But I've never heard of this happening. Hey plaintiffs: See if Saiontz & Kirk will take you for 15 percent.

Posted by Jay Hancock at 9:10 AM | Permalink | Comments (14)
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Wow. Bob Little's blockbuster story on heart-stent implants has dire implications for St. Joseph Medical Center and Dr. Mark G. Midei, one of the center's star doctors. St. Joe has sent letters to hundreds of Midei's patients saying they may have received stents when they didn't need them. In one case reviewed by Little, a patient who received a stent was told his arteries were 95 percent blocked. A review showed the blockage was closer to 10 percent.

Lawsuits are certainly going to fly. Midei, Little says, has lost privileges at St. Joe and stopped practicing. Midei says he expects to be exonerated. The implication, however, is that he may have ordered expensive and potentially dangerous stent implants for patients who didn't need them. If true, it speaks volumes about why the reimbursement system of paying doctors and hospitals per procedure is sending medical costs out of control.

This has been talked about in Washington but not enough. The present system gives doctors and hospitals enormous incentives to perform as many surgeries and tests as they can. Whatever went on at St. Joe, it is likely that other docs and hospitals across the country are enriching themselves by performing unneeded "care". We need to start paying the medical system based on patients' health and outcomes, not per procedure.

St. Joe, which advertised itself as one of the top heart-catheterization shops in Maryland, is doing the right thing by contacting patients. But this has damaged its reputation. "The physician is in charge" of treatment, St. Joe's new CEO, Jeffrey Norman, told The Sun. But he acknowledged that the hospital also bears responsibility. From the story:

Asked if the hospital bears any additional liability for the patients who received stents they didn't need, Norman said:

"I suppose we do. I think that we'll see what comes from these attorneys that are looking for cases, and we'll respond to that."

Posted by Jay Hancock at 8:51 AM | Permalink | Comments (22)
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In today's story by Julie Bykowicz, Senate President Mike Miller held out the prospect that funding for Maryland stem-cell research might be cut. This would be a mistake. The Maryland Stem Cell Research Fund has disbursed more than $50 million in research grants since the legislature approved it in 2006. Cutting the program wouldn't produce that much money to fill budget holes, and it could damage stem-cell momentum in Maryland just when it might be ready to take off.

Here's investment guru John Mauldin:

I think there is a potential for another bubble over the next decade. There will probably be several, but there is one I am particularly interested in and that is biotech, with an emphasis on stem cell and gene therapy and their allied kin. For reasons outlined by my friend Patrick Cox, writer of the newsletter Breakthrough Technology Alert, in today's Outside the Box, I think we are on the cusp of a decade of remarkable breakthroughs which will change the way we do medicine.

Even with its budget disaster, California shows no signs of slowing down its $3 billion stem-cell program, which was ratified by voters. Biotech is Maryland's one hope for a big, private-sector surge in employment and investment over the next decade. Stem-cell money is the seed for the surge. The General Assembly shouldn't cut the water and fertilizer just when it's ready to sprout.

Posted by Jay Hancock at 9:18 AM | Permalink | Comments (7)
Categories: Health Care
        

So I've got three pairs of tickets to see former Labor Secretary Robert Reich at 8 p.m. tonight at the Meyerhoff for the Baltimore Speakers Series. If you want a pair, check out Reich's blog post on how to pay for expanded health coverage and then leave a comment here on whether he's on target or full of baloney or holds the wrong premise (that we need expanded health care). I'll use random.com to do a random drawing among all the decent comments, and winners can pick up the tix at the Meyerhoff will-call window tonight.

Reich opposes the measure to raise money by taxing "Cadillac" health plans:

In any event, I thought a major purpose of health-care reform was to get more care to more people, not to cut it back. Even employees who get extra dollars of wages to make up for the cutbacks won’t necessarily plow those wages back into health care.

He's for the surtax on the rich in the House bill.

But why even take these chances when the House bill simply and cleanly goes after the top 1 percent? It’s not as if couples earning over a million can’t afford to pay the tax. When I last looked, the top 1 percent was taking home a record 23 percent of total income. If anything, the Great Recession is widening the gap. It’s bonus time on Wall Street again. But the middle class is taking a beating.

Posted by Jay Hancock at 11:55 AM | Permalink | Comments (2)
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So we're putting $1,500 into the 2010 family pre-tax medical spending account. The year is less than a week old, and we've already spent $900. The thing gets funded with biweekly paycheck deductions of $57.70. Thanks for the interest-free loan, Tribune Co.

Posted by Jay Hancock at 1:14 PM | Permalink | Comments (0)
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Very nice piece from Paul West this morning on two Maryland doctors on opposite sides of the health-care debate.

Dr. Zaneb Beams is doing everything she can to get Congress to approve health care legislation. Dr. F. Michael Gloth III is trying just as hard to kill it...

Still, Beams said, she cringed when a close friend from college phoned and said, " 'Thank you for all your lobbying on behalf of health care reform.' And I said, 'I'm not a lobbyist!' "...

Gloth said the legislation being debated in Washington would mean more bureaucracy, higher costs and greater inefficiency - and would make matters "much worse" for doctors and patients.

"You don't want to misconstrue my negativity toward this bill as saying that nothing is better than doing something," he said in an interview at a Manor Care nursing home in Catonsville. "But it can't just be change for change's sake. It has to be improvement."

Posted by Jay Hancock at 9:00 AM | Permalink | Comments (1)
Categories: Health Care
        

I'm kind of sorry the Senate health care bill got rid of the "bo-tax" on plastic surgery. Would have been decent way to raise revenue on something nobody except plastic surgeons and Joan Rivers would call a necessity. But the Senate bill now has a 10 percent excise tax on indoor tanning, which seems to have caught the Indoor Tanning Association by surprise.

The ITA's home page has a righteous blast against wise proposals in Baltimore County and Howard County to restrict teen access to tanning parlors. The measures are "an unnecessary intrusion of government in their daily lives" and (channeling Thomas Jefferson here) erode "the freedom of individuals to acquire a suntan." Nothing on the ITA site about the anti-tanning tyranny of the Senate health bill.

The tanning tax is a sensible tax of the sort advocated by A.C. Pigou. It raises revenue and also discourages activity which is harmful and costly to society.

Posted by Jay Hancock at 9:06 PM | Permalink | Comments (2)
Categories: Health Care
        

A retired state worker takes exception to my pointing out that Maryland's spending and liabilities for health-care coverage for retired employees are growing at an unsustainable rate. To cover future retiree medical costs Maryland needs to immediately start appropriating $600 million a year -- as much as will be raised by slot machines if they ever arrive. Liabilities have hit $16 billion and are growing by a billion dollars or so every two years. As in so many other areas of government, we're spending way over our budget. The retiree wants to keep these benefits because they are "hard earned." I'm sure state employees worked hard for these benefits. But the benefits are costing far beyond what either the state or the employees have contributed. What should be done? Here's the note from the retiree:

Here you go again. First you slam AARP, now you're hitting on State Retirees. I am one of those people. When I retired in 2001 from State Service with 36 years, I was promised, on my last day of work, the benefits I now receive for a life without frills. Pick on the real culprits of this problem....drug and health companies with their creamy salaries and profits. The Blue Ribbon Committee you mentioned are waiting for your Republican Congress to let a health bill pass before they act. That seems reasonable. You should know that the delegates that I've communicated with feel that the solution should NOT be on the backs of retired folks, not even current workers, but on new-hires in the future. At least that's what Delegate Lafferty told me in his phone town-meeting a couple weeks ago. Leave us alone. Do you have parents or grandparents on a pension and you want them to lose any part of their hard-earned benefits !??! No way...Shame on you, Jay.

He has a long memory. I slammed AARP three years ago, when I turned 50 and they started stalking me with junk mail.

Posted by Jay Hancock at 11:10 AM | Permalink | Comments (2)
Categories: Health Care
        

AP is reporting that, in exchange for dropping the public option from health-care legislation, liberal Senate Democrats are seeking an expansion of Medicare -- extending Medicare coverage to those as young as 55. (For most people Medicare eligibility starts at 65.) It'll be interesting to see how the Congressional Budget Office scores that. Of course it depends on what the premiums are for the under-65 enrollees, and what's covered. But there is a risk this will inflate the pricetag. Under the public option, the new folks covered under a taxpayer-sponsored plan would have been of a wide range of ages. Under this deal, they'll be concentrated in the late-middle-age/early geezer segment, and therefore subject to more illness and more medical expense.

The new deal would also reportedly have private, nonprofit plans selling insurance nationwide, something that should have been facilitated a long time ago. Now health insurance is chopped up pretty much according to state, which limits competition.

UPDATE: AP's latest story focuses more on the idea of national, private plans filling the "public option" role and downplays the idea of expanding Medicare to younger enrollees.

Posted by Jay Hancock at 9:35 PM | Permalink | Comments (4)
Categories: Health Care
        

The New York Times' Nicholas Kristoff is on a carcinogen and endocrine disrupter binge. He's been writing lately about chemicals in food, water and storage containers that may be messing up our systems. I assume he's getting complaints from industry that he's oversimplifying things, but it's great that he's focusing attention on this stuff. Scientists have done a good job identifying the acutely toxic substances in our lives: tobacco smoke, lead, mercury etc. They're having a harder time identifying the subtly dangerous stuff.

Kristoff keeps harping on the bad molecules that may be leaching out of plastic food containers. His latest advice:

I asked these doctors what they do in their own homes to reduce risks. They said that they avoid microwaving food in plastic or putting plastics in the dishwasher, because heat may cause chemicals to leach out. And the symposium handed out a reminder card listing “safer plastics” as those marked (usually at the bottom of a container) 1, 2, 4 or 5.

It suggests that the “plastics to avoid” are those numbered 3, 6 and 7 (unless they are also marked “BPA-free”). Yes, the evidence is uncertain, but my weekend project is to go through containers in our house and toss out 3’s, 6’s and 7’s.

Posted by Jay Hancock at 8:47 AM | Permalink | Comments (3)
Categories: Health Care
        

Pulled from comments. Jeff Nelligan, a spokesman for Johns Hopkins Medicine, responded to my post (A poor excuse for high Baltimore medical costs) on the comparatively high cost of care at Johns Hopkins Hospital and the University of Maryland Medical Center, as calculated by the Dartmouth Atlas Project. The post referenced a Sunday article in the Sun about the subject and noted that the Mayo Clinic is considered a standard for delivering cost-effective care. I'll respond to Nelligan's comments in italics.

There is no doubt that the Mayo Clinic is a world-class medical center. And there is little doubt The Dartmouth Atlas is valuable in purely assessing Medicare hospital costs. But the Atlas — and the Mayo comparisons — haves limitations that cause us, as well as others, to question their results.

First, the Dartmouth Group began its study years ago focusing on geographic variations. Baltimore is vastly different from Rochester, Minn., home of the Mayo clinic. Our surrounding population also differs dramatically from Mayo’s in terms of income, education, disabilities, crime rates and employment status. For example, 35 percent of our patients are African-American vs. 2 percent for Mayo; 34 percent are below poverty level vs. 5 percent for Mayo; 29 percent are disabled vs. 10 percent for Mayo; 3 percent have a bachelor’s or higher degree vs. 35 percent for Mayo.

This is Jay. A valid point. Different populations present with varying health problems, some of which cost more to treat than others. As Nelligan notes below, Hopkins patients tend to be diagnosed with multiple chronic diseases more often than those at some other hospitals.

Another example is security. Unlike Mayo, we have to maintain a security force of over four hundred professionals to assure a safe campus for our patients, visitors and staff. The most

Continue reading "Johns Hopkins says: Our care isn't too expensive" »

Posted by Jay Hancock at 6:30 AM | Permalink | Comments (12)
Categories: Health Care
        

Excellent piece in yesterday's Sun by Kelly Brewington and Jamie Smith Hopkins on how Baltimore's elite hospitals are responding to the medical-reform debate. With all the discussion about high and unsustainable medical costs, Johns Hopkins Medicine and the University of Maryland Medical Center are under the spotlight for the amounts they charge the system to treat sick people.

American medicine is more expensive than treatment almost anywhere else in the world. The cost of care in Baltimore is even higher than the American average. This bar chart accompanying the article tells the tale. Drawing on data from the widely respected Dartmouth Atlas Project, it shows the expense borne by Medicare for spending in the last two years of chronically ill patients' lives at several hospitals.

As you can see, the expense at the University of Maryland Medical Center and Johns Hopkins Hospital was far above the national average and far above that of the standard-setting Mayo Clinic.

When presented with this kind of data, expensive hospitals always have the same response: Our patients were sicker than the patients at those other hospitals, so we had to bill more to take care of them.

But with this particular data there's a problem with that excuse. Can you see it? The patients at Baylor and the other low-cost hospitals were just as dead after two years as the patients at Hopkins, Mount Sinai and other high-cost places. So it's hard to argue that they were not as ill. 

Posted by Jay Hancock at 6:30 AM | Permalink | Comments (5)
Categories: Health Care
        

GAO found "pervasive deficiencies" in contract management by metro-Baltimore's own Centers for Medicare and Medicaid Services, which run the giant federal health programs. The Government Accountability Office concluded: "The continuing weaknesses in contracting activities and limited progress in addressing known deficiencies will continue to put billions of taxpayer dollars at risk of improper payments or waste."

Note that the problems have to do with contractors Medicare/Medicaid hires to do its job -- administering and auditing claims, keeping computers working, consulting and running the 1-800-MEDICARE phone line. It's work outsourced to the private sector -- not money to pay for medical services. Nevertheless, as someone who supports expanding the Medicare/Medicaid administration's power to run a public health option for all Americans, I admit that the GAO report does not inspire confidence in the organization's competence. GAO said:

These control deficiencies... stem from a weak overall control environment as characterized primarily by inadequate strategic planning for staffing and funding resources. CMS also did not accurately capture data on the nature and extent of its contracting, which hinders CMS’s ability to manage its acquisition function by identifying areas of risk, due to a lack of quality assurance procedures over data entry. CMS also has not substantially addressed seven of the nine recommendations made by GAO in 2007 to improve internal control over contracting and payments to contractors.

Continue reading "Study shows failures in Medicare management " »

Posted by Jay Hancock at 9:29 AM | Permalink | Comments (2)
Categories: Health Care
        

a public option open to everyone (allow states to opt out of this if they dare), Medicare-negotiated drug benefits, no 12-year monopoly for new drugs, and a major squeeze on Medicare reimbursements for doctors -- and have CBO score the savings. I guarantee you, the number will be large.

A public option available to everyone -- not just people who lack insurance -- really would stop costs from rising so quickly. Letting Medicare negotiate lower drug prices would also save money, but probably not as much as Reich thinks. "A major squeeze on Medicare reimbursements for doctors" could have terrible consequences if the targets were primarily general practitioners, who are already getting hammered. The target needs to be specialists -- surgeons, neurologists etc. -- and not just on their fees per procedure (see below).

Reducing patent protections for new drugs is a terrible, terrible idea. Dollar, for dollar, pharmaceuticals are among the best medical investments going. Telling the biotech companies they'll

Continue reading "Warning sign: Reich says health bills too costly" »

Posted by Jay Hancock at 6:51 AM | Permalink | Comments (4)
Categories: Health Care
        

Excellent story by NYT's Robert Pear. Statements by more than a dozen members of congress weren't their own but were written wholly or partly by lobbyists for Genentech, the biopharm company owned by Roche. The statements were put in the Congressional Record, the official archive of the proceedings of Congress.

Pear queried Gententech for a response:

Asked about the Congressional statements, a lobbyist close to Genentech said: “This happens all the time. There was nothing nefarious about it.”

Well, he's half right. It probably does happen all the time. Why is it a scandal when a politician plagiarizes an author or another politician in a campaign speech but not when a multinational corporation programs more than a dozen Chatty Cathy lawmakers and pulls the string?

Posted by Jay Hancock at 5:03 PM | Permalink | Comments (3)
Categories: Health Care
        

Faithful reader Mr. Rational weighs in with a model health plan. This is how you might set it up if you were starting from scratch. But we're not. We have powerful interests wedded to the the inequities, inefficiencies, expenses and failures of the system we already have. Mr. R's scheme (he admits it's "quixotic"), if I have interpreted it right, is this:

1) Have people pay out-of-pocket for everyday medical encounters. That would encourage people to shop for good but inexpensive care. It would yield huge savings in bureaucratic costs. There would be no paperwork. 2) Have primary insurance to cover the odd appendectomy, broken-limb treatment and other "normal" emergencies that crop up throughout life. This would revert medical "insurance" to its true meaning -- a capitalized risk pool for non-ordinary expenses. 3) Have re-insurance from the government for catastrophic, bankruptcy-threatening expenses for say, cancer, car-crash recovery or heart surgery. 4) Devote a separate category of coverage for end-of-life treatment. Mr. R. puts it well:

If we are truly honest we can add a fourth category: Terminal care. Stop pretending that anyone gets out alive by refusing to flog and abuse our elderly and other terminal loved ones and still call it medicine. Most terminal care expenses are covered under Medicare (the elderly) but it still warrants its own category because of how it distorts every other cost statistic. It especially distorts when pointless treatments are used because the misguided emotionality and guilt of survivors mistakenly insist on them.

So we would cut bureaucratic costs in a huge way. We would deploy market forces for everyday care, making consumers spend their own money on medicine instead of somebody else's. We would have a safety net to keep people from going bankrupt. And we would have an honest discussion about why Medicare blows 30 percent or so of its dollars in the last six months of life.

Questions/possible objections: What about pharmaceuticals? Are they out of pocket? Wouldn't many people skip preventive care if they had to pay for it themselves, thus inflating aggregate health-care expense? Doesn't most medical spending come under categories 3) and 4), anyway -- so how will this save money? Thoughts?

Posted by Jay Hancock at 10:35 AM | Permalink | Comments (8)
Categories: Health Care
        

Nice to hear at least lip service from key Democrats over the lack of cost controls in the health-reform legislation advanced so far. Good NYT story from Sheryl Gay Stolberg on intra-Democratic tensions over the tradeoff between making sure legislation has cost-cutting teeth but not enough to hack off medical constituencies who so far have backed it. The Emanuel brothers find themselves on opposite sides. Budget czar Peter Orszag is trying to stifle himself. But his "absolutely" below, answering his own question about whether future cost control will be necessary, means "really, truly, totally yes and I completely mean it -- no matter what's in this bill."

“Let’s be honest,” Rahm Emanuel said in a recent interview. “The goal isn’t to see whether I can pass this through the executive board of the Brookings Institution. I’m passing it through the United States Congress with people who represent constituents.”

He went on: “I’m sure there are a lot of people sitting in the shade at the Aspen Institute — my brother being one of them — who will tell you what the ideal plan is. Great, fascinating. You have the art of the possible measured against the ideal.”

Mr. Orszag would not be interviewed. But in an e-mail message sent through a spokesman, he said the current legislation “lays the foundation” for cost-cutting over the long-term, adding: “Will more need to be done in the future? Absolutely.”

Posted by Jay Hancock at 8:37 AM | Permalink | Comments (6)
Categories: Health Care
        

Portfolio has a good roundup of business lobbies' reaction to the passage of the health-care bill. It's more of the same stuff: Employers will kick people of existing policies. It doesn't cut costs enough. The mandate will hurt small businesses. Etc.

“The current House legislation fails to bend the health care cost curve and breaks the promise that those who like their current coverage can keep it," Karen Ignagni, CEO of America’s Health Insurance Plans, says in a statement.

It's true that the bill doesn't do much about costs. But as somebody said (Andrew Sullivan? I can't remember) it's the Democrats' job to pass entitlements and it's the Republicans' job to control the costs. Still, not addressing costs is a huge flaw in this bill. Especially since today's Republicans seem to have forgotten all about fiscal conservatism. We can't be sure they'll do the job when they regain power.

Unlike the other biz lobbies, Big Pharma waffles. The bill seems to leave it pretty unscathed.

"This is a three-act play and a good critic doesn’t write a review after the opening scenes," Ken Johnson, senior vice president for Pharmaceutical Research and Manufacturers of America, says in a statement. "We are still hopeful that before the curtain comes down on health care reform, the Senate will seriously consider the impact any final legislation will have on U.S. jobs and innovation."

I'm not sure these are just the opening scenes. Seem like Act III, Scene 2 to me.

Posted by Jay Hancock at 9:00 AM | Permalink | Comments (2)
Categories: Health Care
        

I haven't been following this vote-by-vote, but I was surprised to see Kucinich vote "no" on health reform last night. Obviously he wanted single-payer, but I'm nevertheless taken aback to see him vote with the Republicans. Here's part of his statement on why he voted no.

Clearly, the insurance companies are the problem, not the solution. They are driving up the cost of health care. Because their massive bureaucracy avoids paying bills so effectively, they force hospitals and doctors to hire their own bureaucracy to fight the insurance companies to avoid getting stuck with an unfair share of the bills. The result is that since 1970, the number of physicians has increased by less than 200% while the number of administrators has increased by 3000%. It is no wonder that 31 cents of every health care dollar goes to administrative costs, not toward providing care. Even those with insurance are at risk. The single biggest cause of bankruptcies in the U.S. is health insurance policies that do not cover you when you get sick.

Posted by Jay Hancock at 10:13 AM | Permalink | Comments (11)
Categories: Health Care
        

Paul Krugman issues the clarion call:

For this is the moment of truth. The political environment is as favorable for [health care] reform as it's likely to get. The legislation on the table isn't perfect, but it's as good as anyone could reasonably have expected. History is about to be made – and everyone has to decide which side they're on.

And Frank Kratovil forgot to pick up:

WASHINGTON - If Democratic leaders manage to push a massive health care overhaul through the House of Representatives this weekend, they'll have to do it without one of Maryland's Democratic congressmen.

Freshman Rep. Frank Kratovil, facing one of the toughest re-election fights in the country next year, announced Friday that he opposes the measure. His stance could complicate efforts by Democratic leaders to secure approval of the legislation this weekend.

Posted by Jay Hancock at 12:37 PM | Permalink | Comments (7)
Categories: Health Care
        

Funny how Republicans whose jobs or health coverage are in jeopardy favor health-insurance reform in Washington. I've talked to one such family in recent months. Here's another instance. John Hewko, who was a Bush appointee and had to leave government when the administration changed, faces either being uncovered when his COBRA option runs out or enormous premiums from CareFirst BlueCross Blueshield -- as much as $3,000 a month for his family. CareFirst rejected him for standard coverage, he says, because of two pre-existing conditions -- stiffne