Fw: Emailing: www.bioethicsinternational.org

[Guest guest]



Some news.

Find this

Home Contact us FAQ Events Membership Projects About BEI

The Best and Worst of 2007: Health Care

Posted by

January 2, 2008

Unfortunately, 2007 was not a great year for health care in the United States. Every time we seemed to be making a little progress, bad news came rolling in. The fact is that it’s hard to improve a health care system that is designed first, and foremost, to make profits. After all, legally a corporation’s first responsibility is to its shareholders. And corporate executives feel obliged take their own needs into account. The nation’s health just has to take a back seat.

The Massachusetts Health Plan

The Good News: This year Massachusetts’ new health plan covered an additional 300,000 Massachusetts residents. Under the Massachusetts plan, everyone in the state is required to buy insurance (or pay a penalty), with the state providing a 100 percent subsidy for those who earn less than 150 percent of the poverty level. This subsidized health care has turned out to be even more popular than expected.

The Bad News: In November, the Boston Globe reported that this extra enrollment has created a funding gap that could grow to $147 million by the end of the fiscal year. In December, the state board that oversees Massachusetts’ health plan approved cuts of 3 percent to 5 percent in reimbursements to health care providers caring for those in the subsidized plan. Worse still, the board is going to have to decide whether to raise co-pays and other out-of-pocket fees for those whose income is above the poverty level in order to manage costs.

Little wonder Massachusetts is having a hard time funding coverage—the state has the most expensive health care in the world according to a report that came out of Boston University’s School of Public Health. Medicare reimbursement rates, for example, range from $7,000 to $8,000 per enrollee—some of the highest numbers in the nation. The report blamed the high level of spending on the abundance of physicians in Massachusetts and a lack of incentive for them to contain costs. Studies show that supply drives demand. And fee-for-service payments simply encourage doctors to do more. Yet according to health care experts, the quality of care in Massachusetts is no better than in states that spend a lot less. In the end, a big reason why it costs so much to cover Massachusetts is because health care there isn’t very cost-effective. More bad news: this doesn’t seem likely to change anytime soon.

Health Care CEO of the Year

The Good News

McGuire, the UnitedHealth CEO ousted last year in an options-backdating scandal, agreed to give up the rights to $320 million worth of stock options and forfeit $91 million in his retirement plan. That’s on top of $200 million of gains from options with questionable grant dates that he already had agreed to give back to UnitedHealth.

The Bad News

After the giveback, McGuire still has about 24 million stock options, worth in the neighborhood of $800 million. During his tenure at UnitedHealth, he was paid $530 million.

The FDA

The Good News

In December, after months of being urged on by experts and advisers, the FDA banned cough medicine for children under age 2.

The Bad News

Experts actually wanted the ban to apply to children under 6. The FDA’s failure to protect children’s safety only highlights how far the agency has fallen. According to a November advisory panel report, the FDA is in ruins: it lacks scientists, manpower, funding, and even computers. An ABC news story noted that the FDA staff has shrunk by 14 percent over the last fourteen years and that “in the past 35 years, FDA inspections of the food supply have dropped 78 percent due to soaring numbers of products and inadequate FDA funding.â€

Patient Safety

The Good News

In the New Yorker, Dr. Atul Gawande describes what happens when doctors and nurses in Michigan’s intensive care units began using “a stupid little checklist†to make sure that they are doing the right thing at the right time when caring for critically ill patients: within the first three months of the project, the infection rate in Michigan’s ICUs decreased by 66 percent. The typical ICU. cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average ICU outperformed 90 per cent of ICUs nationwide. In the “first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years.â€

The Bad News

Although four years of outstanding results in Michigan have demonstrated the effectiveness of this checklist, no other U.S. hospitals have adopted it, except for s Hopkins, where the list was first developed. As Gawande points out: If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of [these] lists, there would be television ads with Jarvik extolling its virtues, detail men offering free lunches to get doctors to make it part of their practice, government programs to research it, and competitors jumping in to make a newer, better version.

That’s what happened when manufacturers marketed central-line catheters coated with silver or other antimicrobials; they cost a third more, and reduced infections only slightly—and hospitals have spent tens of millions of dollars on them.

But, with the checklist, what we have is . . . hospitals in Rhode Island and New Jersey considering whether maybe they will give this idea a try. Oh, and Spain has signed up to use checklists in its hospitals.

Why the lack of interest in the United States? There is nothing to sell. To make a checklist, all you need is a few pieces of paper and a pencil. Any experienced physician who sat down and thought about it could make up a list. And in our for-profit health care system, when there is nothing to peddle, it seems that people just don’t get excited.

The Unbelievable News

On December30, the New York Times published a shocking op-ed by Dr. Atul Gawande revealing that the administration has brought a halt to the life-saving checklist program both in Michigan and at s Hopkins:

â€this past month, the Office for Human Research Protections shut the program down.,†Gawande writes. â€The agency issued notice to the researchers and the Michigan Health and Hospital Association that, by introducing a checklist and tracking the results without written, informed consent from each patient and health-care provider, they had violated scientific ethics regulations. s Hopkins had to halt not only the program in Michigan but also its plans to extend it to hospitals in New Jersey and Rhode Island.

“The government’s decision was bizarre and dangerous,†Gawande adds. â€But there was a certain blinkered logic to it, which went like this: A checklist is an alteration in medical care no less than an experimental drug is. Studying an experimental drug in people without federal monitoring and explicit written permission from each patient is unethical and illegal. Therefore it is no less unethical and illegal to do the same with a checklist. Indeed, a checklist may require even more stringent oversight, the administration ruled, because the data gathered in testing it could put not only the patients but also the doctors at risk — by exposing how poorly some of them follow basic infection-prevention procedures. [my emphasis]

I do not believe that the reason for shutting down the program has anything to do with medical ethics or patients’ rights I suspect the real reason is buried in that last sentence.

Pharmaceutical Wrongdoing

The Good News

The offices of New York Attorney General Cuomo and New York City Mayor Bloomberg have filed a joint lawsuit against Merck over allegations that the company concealed information about the cardiovascular risks of the COX-2 inhibitor, Vioxx. Merck, which withdrew Vioxx from the market in September 2004 because of safety concerns, faces about 28,000 lawsuits related to the medication in state and federal courts. The lawsuit, filed on Monday in state Supreme Court in Manhattan, seeks restitution for tens of millions of dollars spent on Vioxx prescriptions through the state Medicaid program and state Elderly Pharmaceutical Insurance Program between 1999 and 2004. The city had paid a substantial share of the cost of the Vioxx prescriptions for residents enrolled in the state Medicaid program during those years. The lawsuit alleges that physicians would not have prescribed Vioxx to beneficiaries with pre-existing heart problems had Merck informed them about the cardiovascular risks of the medication. According to the lawsuit, Merck “undertook a concerted and tenacious campaign of false and fraudulent statements to minimize the import and seriousness†of the cardiovascular risks of Vioxx.

The problem, pharmacologists say, wasn’t just that Vioxx was risky; for most patients, it was no more effective than older, much less expensive pain-killers.

The Bad News

Medicare and Medicaid continue to pay for unproven treatments without demanding evidence that they are more effective than older, less expensive treatments. Instead, the government forks over tax dollars if the FDA approves the product. And the FDA requires only that the company provide research that that the new drug is better than a placebo, and that benefits outweigh risks—at least over the short term.

Why doesn’t Medicare ask for proof that the product works? In September, Dr. Steve Phurrough, director of Medicare’s coverage and analysis group gave the Boston Globe a succinct explanation: “If we stopped paying for everything that had no evidence of benefit, we would be a very unpopular organization.†Especially among drug-makers, device-makers, and everyone else who has a brand new health product that they want to peddle “while it still works,†as they say in the pharmaceutical industry—in other words, before we know too much about it.

Maggie Mahar is a Fellow at The Century Foundation. http://www.tcf.org/list.asp?type=NC & pubid=1765

Information and Links

Join the fray by commenting, tracking what others have to say, or linking to it from your blog.

Information January 2nd, 2008 No Responses

Feeds and Links Comment Feed From This Author Del.icio.us Digg Technorati

Categories Bioethics News

Other Posts

What is an ‘ethics consult’ and when should patients get it?

Write a Comment

Take a moment to comment and tell us what you think. Some basic HTML is allowed for formatting.

Name (required)

E-mail (required)

Website

Allow comment box to float next to comments.

Type your comment here.

Reader Comments

Be the first to leave a comment!

Unless otherwise specified, all content is made available under the Creative Commons License.