This National Geographic chart, which I stumbled upon while reading that magnificent magazine on the airplane, truly blew me away. If anyone can look at this and not see a simply insane way to distribute health care, a system so inefficient no socialist country could ever replicate it, then they have stronger rationalization skills than I possess. …

Children on Medicaid Found More Likely to Get Antipsychotics

New federally financed drug research reveals a stark disparity: children covered by Medicaid are given powerful antipsychotic medicines at a rate four times higher than children whose parents have private insurance. And the Medicaid children are more likely to receive the drugs for less severe conditions than their middle-class counterparts, the data shows. …

Slouching Toward Health Care Reform

… Is the effort worth still worth it? Yes, but just. Private insurers will have to take anyone, regardless of preconditions. And some 30 million people who don’t now have health insurance will get it. But because Big Insurance, Big Pharma, and the AMA will come out way ahead, the legislation will cost taxpayers and premium-payers far more than it would otherwise. Cost controls are inadequate; in fact, they barely exist. If Wall Street’s top brass are “fat cats,” as the President described them last weekend, the top brass of Big Insurance, Big Pharma, and the AMA are even fatter. While they don’t earn as much, they’re squeezing the public for even more.

We are slouching toward health-care reform that’s better than nothing but far worse than we had imagined it would be. Even those of us who have seen legislative sausage-making up close, even those of us who never make the perfect the enemy of the better, are concerned. That two or three senators are able to extort as much as they have is appalling. Why hasn’t Reid forced much of the bill into reconciliation, requiring only 51 votes? Why has the President been so cowed? In all likelihood, the White House and the Dems eventually will get a bill they can call “reform,” but they will not be able to say with straight faces that the reform is a significant improvement over the terrible system we already have.

Drug-Makers Paying Off Competitors To Keep Cheap Generics Off Market | TPMMuckraker

… Over the last few years, drug-makers have embraced a startlingly simple tactic for fending off competition from generic brands: paying them off. In a nutshell, the company that holds the patent on a profitable drug strikes a deal with the maker of the cheaper generic brand: you hold off on marketing your generic for several years, and in return, we’ll give you a share of our profits on the drug. …

USPSTF Releases New Screening Guidelines

Mammography screening is in the news again. The US Prevention Services Task Force has announced new guidelines for breast cancer screening that would mean women get fewer mammograms. This is good news.

Read BCA’s analysis of the new recommendations here. On the issue of prevention, click here for information on why words matter.

Bonus: the Washington Post makes a useful point relating this bit of news to health care generally.

The reversal of the seven-year-old guidelines, and the resulting uproar, demonstrate why reducing medical costs will be challenging even with a well-designed health-care reform bill. Ideally, medical practice should follow the evidence. When drugs or procedures are proven to do more harm than good, or to do no more good than safer or less costly alternatives, incentives should be used to discourage them. In practice, though, as new studies overtake old research and new advice contradicts previous guidelines, the result can be confusion and even cynicism — and political pressure to ignore the results.

Late update: Sarah Palin says it’s death panels!

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Health care reform is extremely likely to pass in some form. But let’s not kid ourselves that it’s passing because the Democrats and the public have seen the light and understand that we need to be a more decent society. It’s passing because medical industry has been greedy to the point where it’s now unsustainable. That presented an opening for liberals to enact some policies they have believed in for a long time. But they didn’t do it by making the liberal arguments straight up and have created some kind of strange hybrid system for which the best argument is that it might lead to opportunities for more reform. It’s better than nothing. But it isn’t liberal and it wasn’t designed to be. And just in case, the powers-that-be stuck it to the pro-choicers to make sure nobody got the idea that it was.

The Tools of Doctors, and a Price for Patients

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Technology distances doctors from patients. It creates a compelling alternative reality composed of facts that may or may not be accurate (note all the false alarms created by spurious X-ray findings and aberrant blood tests). It incites considerable public backlash (shortly after X-rays were developed, stores in London were selling X-ray-proof underwear to preserve genital privacy). Then wild enthusiasm takes over (as exemplified by those X-ray shoe-sizing machines of the 1940s).

Medical professionals tend to be the opposite: first enthusiastic and then less so, as the limitations and drawbacks of the toys become clear. At a 1960 medical conference unveiling a new Teflon shunt for long-term kidney dialysis, the audience of doctors and scientists actually rose and cheered. But soon enough they were faced with the painful task of allocating what proved to be an extremely limited resource.

In Seattle, the job of deciding who would live on dialysis and who would die of kidney failure fell to a seven-member committee of laypeople dubbed, in a 1962 article in Life magazine, “the life-or-death committee.” Sound familiar? Only after the 1972 decision to extend Medicare to dialysis patients were these decisions no longer necessary.

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Why Obama Has to do What Letterman Did: Refuse to Pay Hush Money

Last January, as I understand it, the White House promised Big Pharma, big insurance, and the American Medical Association the moral equivalent of what Joel Halderman allegedly demanded of David Letterman: hush money. The groups agreed to stay silent or even be supportive of healthcare reform, as long as they were paid off.

But now that it’s time to collect, the bill is larger than the White House expected, and it’s going to fall like an avalanche on middle class Americans in coming years. That means an ugly 2012 election (read Sarah Palin).

So the President has to do what Letterman did: Refuse to pay.

Big Pharma is on the road to getting its deal: not only 25 to 30 million more paying customers, but also a continued ban on Medicare using its bargaining clout to reduce drug prices, a bar on genetic drug manufacturers introducing similar biologic drugs until the originals have been on the market at least twelve years, and no public insurance option to negotiate low drug prices.

Big insurance is on the way to getting what it wants: 25 to 30 million more paying customers (many of them young and healthy), a requirement that almost all businesses “pay or play,” and no competition from a public option.

Doctors (that is, the American Medical Association) are on the way to getting what they want: Instead of a temporary patch on scheduled decreases in Medicare reimbursements to them, a permanent fix that would change the reimbursement formula altogether and reward them $240 billion over the next ten years.

But when they all get paid off, who will do the paying? Middle-class Americans who are already in a financial squeeze — whose wages are lower, adjusted for inflation, than they were thirty years ago, and whose jobs are disappearing. They’ll face still higher premiums, co-payments, and deductibles; and they’ll pay higher drug prices, Medicare premiums, and taxes to cover the rest.

That’s because these payoffs make it next to impossible to contain the wildly escalating costs of health care.

The only thing in the emerging bills that’s related to cost containment is a proposed excise tax on so-called “Cadillac” insurance plans, costing over a certain threshold amount (the threshold is now up for grabs). But because the costs of health care are likely to rise faster than inflation, whatever threshold, the middle class will get socked again.

So Obama has to forcefully weigh in with Nancy Pelosi and Harry Reid as the two try to cobble together passable bills for each chamber — demanding real cost containment.

The three big ones: (1) A true public option (better yet, one that allows anyone now holding private insurance to opt into). (2) Authority for Medicare to negotiate low drug prices. And (3) Lower Medicare reimbursement rates to doctors (in other words, no “doctor fix”).

In addition, the so-called “medical exchanges” in the emerging bills (as well as the public option, which hopefully will be included) should give preference to pre-paid heathcare plans, like Kaiser Permanente, whose doctors are on salary and have every incentive to keep people healthy rather than charge for more services and tests.

But if Obama doesn’t weigh in and say “no” to the hush money for Big Pharma, big insurance, and the AMA, America’s middle class will get walloped. And if the walloping starts before 2012, Sarah Palin or some other right-wingnut populist will wallop Obama, and then will wallop America.

Diagnosis: What Doctors Are Missing

A fascinating and somewhat disturbing article at the New York Review of Books by Jerome Groopman looks at what counts for progress in medical diagnosis and finds it to be more of a mixed bag than most readers would assume. This won’t come as much of a surprise to those who know a bit about the field (one of my colleagues who worked at the National Institutes of Health called it “a medieval art”). But what is a tad disconcerting is that the efforts to make medicine more scientific may not in fact be a plus.

That may sound simply bizarre to readers. Isn’t evidence based medicine a good thing? Well, maybe not.

One of the reasons this piece struck a chord with me is that some of the efforts to make medicine more scientific parallel, in their negative aspects, the push to make economics more scientific. In medicine, this means developing more rules and tools for diagnosis; in economics, the course chosen was to impose more “rigor” which meant make greater use of mathematical exposition (proof-like theoretical papers) and to have “empirical” papers centered around statistical analysis of data sets.

Now while this all may sound well and good, in fact, both are methodological choices that limit investigation. For instance, evidence based medicine seeks to gather symptoms and then use that to determine what the ailment might be. Well, the problem is these protocols have been developed from people with only one thing wrong with them. Many people who show up in doctor’s offices have multiple pathologies. So a lot of effort is being expended to develop an approach that has limited value in the field, and worse, doctors are increasingly expected to conform to it.

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The fear of lawsuits among doctors does seem to lead to a noticeable amount of wasteful treatment. Amitabh Chandra — a Harvard economist whose research is cited by both the American Medical Association and the trial lawyers’ association — says $60 billion a year, or about 3 percent of overall medical spending, is a reasonable upper-end estimate. If a new policy could eliminate close to that much waste without causing other problems, it would be a no-brainer.

At the same time, though, the current system appears to treat actual malpractice too lightly. Trials may get a lot of attention, but they are the exception. Far more common are errors that never lead to any action.

After reviewing thousands of patient records, medical researchers have estimated that only 2 to 3 percent of cases of medical negligence lead to a malpractice claim.

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Medical errors happen more frequently here than in other rich countries, as the Robert Wood Johnson Foundation recently found. Only a tiny share of victims receive compensation. Among those who do, the awards vary from the lavish to the minimal. And even though the system treats most victims poorly, notes Michelle Mello of the School of Public Health at Harvard, “the uncertainty leads to defensive behavior by physicians that generates more costs for everyone.”

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So the most promising fixes are the ones that don’t treat the malpractice system as an isolated issue.

Imagine if the government paid for more research into which treatments really do make people healthier — a step many doctors don’t like. Such evidence-based medicine could then get the benefit of the doubt in court. The research would also make it easier to set up “health courts,” with expedited case schedules and expert judges, which many doctors advocate.

Similarly, you would want to see more serious efforts to reduce medical error and tougher discipline for doctors who made repeated errors — in exchange for a less confrontational, less costly process for those doctors who, like all of us, sometimes make mistakes.

A grand compromise along these lines may be unlikely. But it’s a lot more consistent with the evidence than narrower ideas. The goal, remember, isn’t just to reduce malpractice lawsuits. It’s also to reduce malpractice.

Makes sense to me.