Vol. 64 April 1, 2012 Breaking Medical News

April 1, 2012


The Food and Drug Administration announced yesterday approval of the new drug, Viagrator, a combination of Viagra and Lipitor. Pfizer has been seeking lost revenues since Lipitor’s patent expired,and the demographics of the users of Viagra and Lipitor are almost identical. Combining the two into one capsule is a slam dunk. Viagrator will still carry a warning about the need to call a doctor if effects last for more than 4 hours, but new information that a double-cheese omelet can reverse it will be added.

Pfizer is searching for an appropriate celebrity to serve as a symbol of both sexual prowess and high cholesterol to promote its new product. Industry sources report that Newt Gingrich is the leading candidate, but doubt that a contract can be signed before November.


In Medicare’s quest to become more like Visa with single swipe payments, timely and understandable statements, and better fraud protection Medicare has announced its own frequent flyer reward points program. Each Medicare dollar spent on medical care will earn points for the patient that can be redeemed for other medical services. The rewards menu is quite complicated. For example, 4 MRI’s earn you enough points for a colonoscopy. Points from 6 EKGs can be redeemed for a week’s supply of Inderal or nitroglycerine. The medical device rewards catalog includes a CPAP machine after 8 visits to a pulmonologist. a walker after 2 visits to an orthopedist or 4 visits to a neurologist, and a high-seat toilet after the second hip or knee replacement.

The AMA has come out strongly against the use of Medicare reward points for travel to other countries for surgery, and the American Society of Plastic Surgeons has refused to participate in the rewards program at all. They are still mostly “cash up-front”. Efforts by the Obama administration to use the program as a Medicare cost-cutter by deducting points for inappropriate care (for example, after 4 visits to an ER in 6 months you would LOSE 200 points) have been rejected by Congress so far.


A new twist to the current controversy about paying for abortion and birth control pills was recently put into the other side of the intercourse equation. An enterprising group of urologists is offering a free pizza if you get a vasectomy in March. The free pizza is touted to help you recover post-operatively as you watch March Madness on the tube. I wonder what you could get for a tubal ligation? … an Easter dinner for 6?


Some Blue Cross/Blue Shield policyholders recently received a notice that in 2012 the healthcare insurer will reimburse up to $150 for fees in health fitness clubs or structured weight loss programs for its subscribers. The response was so positive that BC/BS’s initial caution quickly turned to such enthusiasm that BC/BS plans to make fitness club membership MANDATORY for its subscribers on July 1,2012.

Acturarial analysis suggested that members needing walking assistance devices, specially modified automobiles, or wheelchairs be excluded from this requirement. This suggestion was ignored when AARP pointed out that many “thousands and thousands of AARP members” used canes. Legal counsel expressed concern in today’s environment about potential law suits against this “individual mandate”. BC/BS officials dismissed the concern with “Hey, it’s not like we’re mandating that everyone eat broccoli!


Now that sexting has become prevalent, what’s next? Well, we are in a capitalistic society that rewards entrepreneurs, so you guessed it, a one-day California conference to develop apps for it. Why not unleash, and even incentivize, the most creative, innovative minds of our society to help us deal with “unmentionables”?

The call is out to….“design an app to solve the challenge of providing honest, real-time, private data from youth and young adults about “unmentionable” activities, like sexual behavior, substance use, sadness, and relationship drama to researchers and program experts who work with youth.”

The reason to do this is that…“the health field has been trying to prevent the most common adolescent and young adult health problems since time began: sexually transmitted diseases, depression, substance abuse and dating violence. By the age of 25, more than 90% of young adults will have experienced more than one of these problems, and for some youth, the consequences will be lifelong (infertility, homelessness, brain injuries, etc.).”

“It’s almost impossible to know what works in terms of prevention efforts, as health researchers rely on survey answers given by youth after the fact with questions such as: How many times did you use a condom for sex in the last six months? Now, really, who remembers?”

“We want to put the best and brightest minds in tech behind the solution. We want an app where young people are enticed and excited to share their Unmentionable data – data about the whos, whats, wheres and whens of their risk behaviors – in the moment or soon after.”

Interested? Too bad, it’s already over. March 31 in San Francisco.


Vol. 50 August 15, 2011 “Want To Go Dutch?” …or French…or German?

August 15, 2011

Before we learn FROM other countries’ experiences with medical care,

we first need to learn ABOUT them. (1)

Since all other developed countries have universal health care insurance it is a no-brainer that we, the sole remaining developed country without universal health care insurance, should look to other countries’ experiences for help in our incremental struggle towards it. Looking to the United Kingdom’s NHS has been the most frequent step because of our common language. It has also been the most politically risky one because of the potential stigma of being labeled as “soft on Socialism”. All Dr. Berwick had to say was that there were parts of the NHS that he thought were good, and he was immediately barraged by Congressional criticism as the interim head of Medicare.

So, what about France and Germany that have 5% administrative costs as compared to our 20%? (Remember, Capital One Visa card charges about 7-8% to its users.) We spend around 16% of our gross domestic product on healthcare while the French (see SICKO by Michael Moore, 2007) and the Dutch spent around 10-11% in 2007. You are already familiar with peri-natal morality rates and other measures of quality showing that our health status is no better and is sometimes even worse than those countries despite our higher costs.

2007    Infant      Mortality  Life Expectancy
Germany    4.1 79
France    4.2 79.9
Canada    4.6 80.3
U.K.    5 78.7
U.S.    6.4 78

…the DUTCH ? !

The recent proposal from Congressman Paul Ryan (R-WI) to replace traditional Medicare with a voucher system for individuals to purchase private health insurance brought the Dutch universal health care system into our spotlight. Both Ryan’s Plan and the Dutch system rely on regulation of private insurance, so-called “managed competition”. In 2006 the Netherlands switched from a system of mandatory social insurance administered by nonprofit sick funds to mandatory basic insurance that citizens had to buy from private insurance companies.

A recent analysis of the Dutch system (1) indicates that despite the intention to control costs while continuing universal access, the reality of “managed competition” has fallen short in four key areas:

1. the growth of health care spending has NOT slowed and the administrative cost and complexity has increased (600 workers were added to the tax department to verify eligibility and dispense vouchers),

2. the number of Dutch people who have “defaulted” on their premiums and have, therefore, become “uninsured” has increased the number of uninsured from 1.5% to 3%,

3. the value of “consumer choice” has proved to be very small with an average of only 4% per year changing their insurance between the 4 insurance conglomerates that control 90% of the health insurance market,

4. the amount of government regulation did not decrease; price controls, global budgets, and patient cost-sharing remained in effect. (In 2010 payments to specialists were reduced in response to budget overruns)

The Dutch Ministry of Health requires that insurance companies accept all applicants regardless of health status and must charge only community-rated premiums to avoid “cherry picking” of the most healthy portions of the population. Also, risk equalization formulas are used to protect insurance companies from excessive losses incurred by the sicker, higher-risk populations. Insurance companies are expected to compete in price and quality through SELECTIVE contracting with networks of hospitals and physicians. These same policies are shared by many of the health care reform proposals in the U.S., including Ryan’s Plan.

The actual outcomes of this “managed competition” in the Netherlands include:

  • total costs of health insurance for Dutch families has increased by 41% since 2006
  • the country now spends 15% of its gross domestic product on health care rather than 10%
  • more than 40% of Dutch families receive government subsidies to pay their health insurance premiums, and that will increase as the government moves to protect “defaulters” from losing their insurance after six months of non-payment of premiums.
The article ends with this statement:
“The idea that the Dutch reforms provide a successful model for U.S. Medicare is bizarre.”
The Ryan Plan is based on the same principles, but would also gradually reduce governmental contributions so that a 65 year old beneficiary would pay for 2/3 of his or her medical costs. It is obviously no panacea for U.S. health care insurance problems.

1. Managed Competition for Medicare? Sobering Lessons from the Netherlands , NEJM 365:4 , p. 287, July 28, 2011, Okma, Marmor, and Oberlander

Vol. 42 April 1, 2011 Updates on Health Care Reform

March 31, 2011

“You can always count on Americans to do the right thing – after they’ve tried everything else.”
-Winston Churchill

Mitt Romney announces his candidacy for Governor of Massachusetts

Persistently harassed by Tea Party leaders and other conservative Republicans for the inclusion of the “individual mandate requirement” in his Massachusetts Health Care Reform Act and tired of defending it as “good for Massachusetts but not necessarily for [insert name of any state in which Romney is that day]”, Mitt Romney has announced that he will abandon his exploratory campaign for the Presidency. He will return to Massachusetts to run for Governor against Duval Patrick. “Since this annoying issue of the individual mandate just won’t go away, I am going back to Massachusetts to undo it,” said Romney.

Donald Berwick, MD apologizes to Congress for his extreme behavior during his hearing

Though most reviewers remarked on Dr. Berwick’s evenhanded responses to the sometimes hostile questioning at the Senate Finance Committee hearing on his nomination as CMS Administrator, this blogger has a different view. I was present in the hearing room just after the TV cameras and microphones were turned off. Dr. Berwick, having kept his cool for so long, literally exploded, cussing the senators for their “mean-spirited, narrow-minded, myopic views of the federal government’s role in health care”. “Arguing with you is like talking to a dinner table.” When this outburst hit You Tube via someone’s cell phone the next day, Dr. Berwick quickly apologized. “As a pediatrician I thought I knew how to control temper tantrums, but somehow that hearing just conjured up all the adolescent turmoil that I thought I had outgrown, and I flew off the handle. I am extremely sorry, but am very thankful that my staff took away my iPhone before I was able to tweet.”

President Obama was so shaken by Dr. Berwick’s outburst that he has begun seeking a replacement; one who has experience in public policy, is a strong individual, is acceptable to most Republicans, and who is currently unemployed.  Arnold Schwarzenegger springs to my mind, though he is rumored to have returned to acting, “I lift things up and then put them down.”

Sarah Palin withdraws her opposition to “Death Panels”

According to David Williams writing for the Health Care Blog: “Chief among Sarah Palin’s assaults on truth and reason is her contention that providing reimbursement for end-of-life planning sessions with a health care provider is tantamount to a “death panel” where a “bureaucrat can decide based on a subjective judgment of [a person’s] ‘level of productivity in society,’ whether they are worthy of health care.” One ingredient of end-of-life planning is patients’ opting for palliative care. He summarized a recent study in New York state where patients who received palliative care cost Medicaid almost $7000 less in hospital costs per admission than a matched control group that didn’t receive palliative care. Patients receiving palliative care spent less time in the intensive care unit and were less likely to die there. They were also more likely to receive hospice care after discharge and to be discharged to appropriate settings.

Impressed by this report and other studies, Sarah Palin has withdrawn her opposition to the reimbursement of  “Death Panels” to help patients and families plan for end-of-life care. However, her newly found acceptance of rational end-of-life care is tempered by the unintended consequence of the increased satisfaction of families receiving palliative care.  “Most people on Medicaid are unemployed, deadbeats, or probably illegal immigrants, so why should we be spending time and money increasing their satisfaction with our health care system?”

Starbucks will add Urgi-Care Centers to their stores

Howard Schulz, CEO of Starbucks, announced that as of April 1 they would be establishing urgent care counters in selected urban stores. He is impressed with the successful implementation and rapid growth of convenient medical service centers in CVS pharmacies and wants to remain competitive in the crowded field of one-stop-service retail stores. According to Schultz, “Starbucks is the quintessential experience brand and the experience comes to life by our people.  The only competitive advantage we have is the relationship we have with our people and the relationship they have built with our customers.”

Analysts remark that this move is consistent with Starbuck’s image as a “home away from home and work” where one can go to relax, listen to music, buy a CD, work on a computer, read a newspaper, eat a snack, trip over a stroller, smile at the dogs tied up outside the door, and …get a cup of coffee.

Schulz also announced that a new flavor shot, “Potassium Iodide”, will be introduced in selected West coast stores in response to recent consumer inquiries there. Despite the phenomenal growth of medical marijuana stores in California and Colorado, Starbucks has no current plans to add this to their offerings. “A double espresso mocha caramel Vente is as high as you can go at Starbucks for the moment.”

Congress to hold hearings on what to call the new medical care payment system

The Accountable Care Organizations (ACO) proposed by the Affordable Care Act (ACA) will require the replacement of fee-for-service provider payments with a collecting together of all kinds of medical care bills which will then be paid out of a single account. Congress has known for a long time that no one knows what “ACO” means, and now, no one seems to agrees on what to call this new billing and payment method. The CMS, GAO, AMA, AHA, and AAMC just issued issued a report of their study of possible labels and asked for congressional hearings on their conclusion. Here are selected samples of the rejected names and their recommended conclusion:

“fee-splitting”– Though functionally similar to ACO methods the AMA objected to this because of their successful, long time efforts of labeling it as unethical.

“capitation” (also called “capitation-light” or “neo-capitation”) – Again, though functionally very similar to the ACO method, it was felt that this word had too many negative political, economic, and patient-control associations.

“global payments” – This one was very popular and is still in use by some people, but the negative associations with the weird weather we are having and with Al Gore nixed it. The fact that “global” corporations seem to be very successful in  avoiding anti-trust litigation was a definite plus for this label.

“rational budget allocation” – Sounded too much like the U.K. National Health Service,  definitely requires the advance planning dreaded by most physicians, and the  second word was the only one with a meaning accepted by all.

“single payment to all medical providers for a patient’s illness for life” (SPAM PILL)- An accurate statement, but much too long for an acronym or sound bite, and though the acronym implies a use of electronic networking (good), it has an  annoying connotation (bad).

After many meetings, exhaustive staff work, and numerous drafts of over 100 pages each the report finished with this final conclusion:

‘The one word that captures the collective nature of the new payment system with both warm, fuzzy connotations and a positive image is ‘bundling’, as in the soft, warm bundling of a baby in a blanket. Who could be threatened by that?”


Vol. 40 March 1, 2011 Health Care Reform: Politics, Computers, and the Individual

March 1, 2011

There are always three solutions to any issue;
the perfect solution,
no solution,
and the one we get.

-Deval Patrick, Gov. of Massachusetts, referring to the Health Care Reform program in Massachusetts

For those of you who, like me, are having a hard time keeping track of the latest Senate and House bills and head counts, periodic promises of vetoes, contradictory federal court decisions, and a veritable blizzard of acronyms, here are some brief reflections to help maintain focus on the important issues.

Of course it is. Gov. Deval (Dem) just complimented past-Gov. Romney (Rep) on the excellent job he did crafting and getting passed the Massachusetts Health Care Reform Act of 2006.  It “guaranteed heath insurance to everyone and incentivized cost reduction and improved quality” AND included the individual mandate (see below). Romney is quietly aghast because he is trying to woo conservatives Republicans for his 2012 run for the presidency, and they want to scuttle the federal program which is modeled after his Massachusetts program. Romney’s response is to proclaim that not every state has to do the same thing, “What is good for Massachusetts is not necessarily good for Mississippi ( or Alabama, or North Dakota)”. That sounds great to proponents of  “States’ Rights” (wasn’t that one of the battle cries of the Civil War?), but the states have no money either. They want to be able to blame the federal government for the increasing cost of providing health care to everyone.

Meanwhile President Obama reminds us that his program allows states in 2017 “to do their own thing” if they think they can “insure everyone while reducing costs and improving quality”. He just announced his support of Senator Brown’s bill pushing that time period forward to 2014. (This clever “calling their bluff” might help deflate the distracting federal vs. states debate.) The “States Rights” guys are now aghast, because they would prefer  to stop Obama’s federal plan in the courts by attacking the individual mandate as unconstitutional rather than being held accountable to come up with viable state-based reforms.

Depending on your view the Massachusetts program is working or it is bankrupting the state. If you check out these references and look for others, you will see that there seems to be little data on the results of the Massachusetts bill after 2009. As a physician who believes that health care needs reforming, I can only hope that Don Berwick, MD and others who are busily supporting innovations and reform will be able to show us the data on what is working and what is not before politics completely obscure the original goals.

HIT, EHR, EMR, mHEALTH, and HITECH are all computerized medical information terms,
or are part of the sequel song to “Initials” in Hair.
While plans to build expensive proprietary systems proceed with all deliberate speed, physicians are rapidly buying iPhones, iPads, and Blackberrys to both enjoy and benefit from the easy connectivity to the rest of the world. The last time I pulled the Physician’s Desk Reference (PDR) off the shelf to check a prescription was last year, which was a year later than the last time my nurse did. There are over 500,000 apps for “smart” devices, but what do we all really value? CONNECTIVITY. Connectivity allows all sources of medical information and, by the way, maybe the patient, to communicate directly and easily. Neither the U.S. nor the U.K., which has been spending millions on its national program to computerize medial information for years, has developed standards for connectivity.”…[Without connectivity] this potentially transformational technology will simply create one more way for different health care providers to talk past each other”. (1)

The individual mandate requires almost all legal residents of the United States to have at least a minimum level of health care coverage through their employer or purchased by themselves individually. Those lacking such coverage will be subject to a penalty to be paid as part of tax filing. (The wages and benefits for thousands of new IRS agents to enforce this regulation is a significant cost of the bill.) Eligible low-income people will be helped in complying with this mandate by government-run insurance exchanges and government-subsidized policies.

This mandate is supported by the health care insurance industry because it promises that the industry will gain 30 million new customers. In fact, this provision causes some to label the current health care reform act as the “preservation of the private health care insurance industry.” It was meant as a sweetener to offset the mandate to the insurance companies to NOT deny coverage to anybody for pre-existing conditions. The precedents for the individual mandate touted by its proponents go all the way from the Militia Act of 1792 to current state requirements for auto insurance. Ah hah! There is that “state” word again. Maybe that is why conservatives attack this federal provision even though it is supported by big corporations and was originally developed by fellow Republican Mitt Romney .

1. Boston Globe editorial March 1, 2011

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