HealthLawProf Blog

British Health Care v. American Health Care

Ezra Klein takes on Andrew Sullivan on health care and which system, the British or American, provides better results.  It is quite a fun read.  Here is Andrew Sullivan's view on why the British are more satisfied with their health care services,

Satisfaction is a subjective function of subjective expectations. If you have the kind of expectations that many Brits have for their healthcare system, it is not hard to feel satisfied. The Brits are very happy with their dentists as well. And there is a cultural aspect here - Brits simply believe suffering is an important part of life, especially through ill health. Going to the doctor is often viewed as a moral failure, a sign of weakness. This is a cultural function of decades of conditioning that success is morally problematic and that translating that success into better health is morally inexcusable. But if most Americans with insurance had to live under the NHS for a day, there would be a revolution. It was one of my first epiphanies about most Americans: they believe in demanding and expecting the best from healthcare, not enduring and surviving the worst, because it is their collective obligation. Ah, I thought. This is how free people think and act. Which, for much of the left, is, of course, the problem.

Ezra Klein responds,

Then we could ask the question: Do the Brits seems to be in worse health? Do they have a health care system that delivers worse outcomes? The answer to both is no. In the case of ill health, they're actually in much better health than their American counterparts, though that's a function of lifestyle more than hospital choice. And in the case of health outcomes, it sort of depends. You're probably better off getting your breast cancer treated in America and getting your diabetes treated in Britain. In the aggregate, however, the evidence is fairly clear that the British are better off. Health researchers look at a measure called “amenable mortality,” which refers "to deaths from certain causes that should not occur in the presence of timely and effective health care." In other words, deaths that are prevented by contact with the health care system. If Andrew is right that those stoic Brits just grit their teeth and bear their illness, this measure should be much higher in Britain than in the US.

But it's not. In concert with Andrew's thesis, Britain does indeed have a high rate of amenable deaths. Just not higher than ours. . . . But either way, the difference between the American and British health care systems is not that we are enjoying timely and lifesaving interventions while they are forgoing them.

He further adds,

. . . the correct question is not whether Americans would want the National Health Service. The question is whether they'd want the National Health Service and a $4,000 check every year. 10 years under the British health system, and Americans would have an extra $40,000 per person (more if you account for inflation and spending growth). That's the choice. The British choose a more restrictive health care system -- and yes, the word is choose, they could vote to dismantle it, or fund it differently -- because that gives them a cheaper health care system. And I'm much less certain than Andrew that my countrymen have made some sort of explicit decision to demand the right to pay $4,000 more than the British for care that is not measurably better. responds,

Health Reform Moving Forward

The Wall Street Journal reports today that health reform is still alive - even as we see the economy worsen.  Laura Meckler writes,

Former Sen. Tom Daschle, who is slated to oversee health-care policy in the Obama administration, is kicking off the effort to pass a comprehensive health-care plan. In a speech to be delivered Friday in Denver, Mr. Daschle will say, "The president-elect made health-care reform one of his top priorities of his campaign, and I am here to tell you that his commitment to changing the health-care system remains strong and focused."

Mr. Daschle will emphasize the importance of moving forward even amid the economic crisis, noting that rising health-care costs put more pressure on businesses and must be addressed. The speech does not lay out any specific timetables for action on health care by the Obama administration.

Mr. Daschle, who Obama transition officials say will be nominated secretary of Health and Human Services, will suggest that Americans hold holiday-season house parties to brainstorm over how best to overhaul the U.S. health-care system. He will promise to drop by one such party himself, and to take the ideas generated to President-elect Barack Obama. . . .

"There is no question that the economic health of this country is directly related to our ability to reform our health-care system," Mr. Daschle will say in his prepared remarks. The former Senate majority leader will be speaking as head of the Obama health-care transition team, because his nomination to head HHS has not yet been announced. . . .

Already, the Obama transition office has posted two health-care videos on its Web site, www.change.gov, and it is soliciting comments and ideas from people via the site. So far, it has received more than 10,000 comments, according to Mr. Daschle's prepared remarks. Those who want to host health-care parties are asked to sign up on the site.

For a terrific overview of some of the competing health care reform proposals, see this post from DemFromCt at DailyKos. 

New Report Finds No Link Between Abortion/Depression

Thinkprogress has a short story summarizing the report from Johns Hopkins University that finds no scientific support for claims that abortions cause "psychological distress, or a 'post-abortion syndrome.'" Yahoo News reports further on the study, stating

No high-quality study done to date can document that having an abortion causes psychological distress, or a "post-abortion syndrome," and efforts to show it does occur appear to be politically motivated, U.S. researchers said on Thursday.

                        

A team at Johns Hopkins University in Baltimore reviewed 21 studies involving more than 150,000 women and found the high-quality studies showed no significant differences in long-term mental health between women who choose to abort a pregnancy and others.

                        

"The best research does not support the existence of a 'post-abortion syndrome' similar to post-traumatic stress disorder," Dr. Robert Blum, who led the study published in the journal Contraception, said in a statement.

                        

"Based on the best available evidence, emotional harm should not be a factor in abortion policy. If the goal is to help women, program and policy decisions should not distort science to advance political agendas," added Vignetta Charles, a researcher and doctoral student at Johns Hopkins who worked on the study.

Flu Advice From Cell Phone

The Associated Press is reporting on a new cell phone feature - warnings about the flu virus.  The AP states,

A maker of over-the-counter cold and flu remedies released a program this week for the T-Mobile G1, also known as the "Google phone," that warns the user how many people in an area are sneezing and shaking with winter viruses.

The "Zicam Cold & Flu Companion" will say, for instance, that 8 percent to 14 percent of the people in your ZIP code have respiratory illnesses, representing a "Moderate" risk level. To give germophobes and hypochondriacs even more of a thrill, it also says what symptoms are common, like coughing and sore throat.  Matrixx Initiatives Inc., the Arizona company that makes products under the Zicam brand, gets the information on disease levels from Surveillance Data Inc. — which gets its data from polling health care providers and pharmacies. . . .

Google Inc., which created the G1's operating system, launched its own state-by-state Web-based flu tracker recently. It's based on the number of people plugging flu-related searches into Google's search engine.

YouTube Medical Device Ads: Violation of FDA Rules?

Yesterday's Wall Street Journal's Health Blog ran a short post on the use of YouTube videos to advertise medical devices and challenges to those ads by Prescription Project, an advocacy group backed in part by the Pew Charitable Trust.  I must admit in my YouTube searches the term medical device has never been of great interest, however, it must be for some because companies are using YouTube to advertise their products.  Jonathon Rockoff reports,   

The Prescription Project says YouTube videos for medical devices made by Abbott, Medtronic and Stryker violate federal rules because they don’t contain required warnings and disclosures. And the group wants the FDA to do something about them.

The companies tout the virtues of the devices without also stipulating the risks that patients need to know before deciding whether to use the products, Allan Coukell, the Prescription Project’s director of policy, told the Health Blog. . . .

The Prescription Project urged the FDA, which has warned some drugmakers about Internet ads, to update its advertising rules to specifically apply to the growing role of on-line marketing. . . .

Residency Bad for Patients

Ezra Klein has a great post on the need to reform residency programs.  He writes,

Being a medical resident is bad job. 80-hour workweeks, . . .

But being the patient of a medical resident is arguably worse. A tired doctor makes mistakes. And mistakes can kill you. Which is why I have so little patience for the caterwauling around new rules meant to impose some minimal regulations on how hard residents work. How minimal? 16-hour workdays. And the next one can start after a five hour nap period. Of course, this is merely an Institute of Medicine report making these recommendations, and thus it's not binding, and won't be enforced. And so patients will die, and medical malpractice premiums will rise, and doctors will complain, and all so we can keep this bizarre program that understands apprenticeship as a mixture of masochism and cost-cutting.

NICE's Cost/Benefit Analysis

The New York Times' Gardiner Harris reports on the balancing of costs and benefits of drugs in England and impact that has on other countries as all try to cope with the rising drug prices.  He writes,

When Bruce Hardy’s kidney cancer spread to his lung, his doctor recommended an expensive new pill from Pfizer. But Mr. Hardy is British, and the British health authorities refused to buy the medicine. His wife has been distraught. . . . 

If the Hardys lived in the United States or just about any European country other than Britain, Mr. Hardy would most likely get the drug, although he might have to pay part of the cost. A clinical trial showed that the pill, called Sutent, delays cancer progression for six months at an estimated treatment cost of $54,000.  But at that price, Mr. Hardy’s life is not worth prolonging, according to a British government agency, the National Institute for Health and Clinical Excellence. The institute, known as NICE, has decided that Britain, except in rare cases, can afford only £15,000, or about $22,750, to save six months of a citizen’s life.  British authorities, after a storm of protest, are reconsidering their decision on the cancer drug and others.

For years, Britain was almost alone in using evidence of cost-effectiveness to decide what to pay for. But skyrocketing prices for drugs and medical devices have led a growing number of countries to ask the hardest of questions: How much is life worth? For many, NICE has the answer.  Top health officials in Austria, Brazil, Colombia and Thailand said in interviews that NICE now strongly influences their policies.  “All the middle-income countries — in Eastern Europe, Central and South America, the Middle East and all over Asia — are aware of NICE and are thinking about setting up something similar,” said Dr. Andreas Seiter, a senior health specialist at the World Bank.

Even in the United States, rising costs have led some in Congress to propose an institute that would compare the effectiveness of new medical technologies, although the proposals so far would not allow for price considerations. At the present rate of growth, medical costs will increase to 25 percent of the nation’s gross domestic product in 2025 from 16 percent, with half of the increase coming from new drugs and devices, according to the Congressional Budget Office.

To arrest this trend, the United States needs to adopt at least some of NICE’s methods, said Dr. Mark McClellan and Dr. Sean Tunis, who served earlier in the Bush administration as, respectively, administrator and chief medical officer of the Center for Medicare and Medicaid Services. Dr. Tunis said he spent a lot of time in government “learning about NICE and trying to adopt the processes and mechanisms they used, and we just couldn’t.” That’s because the idea of using price to determine which drugs or devices Medicare or Medicaid provides has provoked fierce protests. But Dr. McClellan said the American government would soon have no choice.

Drug and device makers, which once routinely denounced the British for questioning product prices, have begun quietly slashing prices in Britain to gain NICE’s coveted approval, especially because other nations are following the institute’s lead. Companies have said that they will consult with NICE to help determine which experimental compounds enter the final stage of clinical trials, so the British agency’s officials will soon influence which drugs enter the market in the United States.

The British government created NICE a decade ago to ensure that every pound spent buys as many years of good-quality life as possible, but the agency is increasingly rejecting expensive treatments. The denials have led to debate over what is to blame: company prices or the health institute’s math.

Dr. Michael Rawlins, chairman of NICE, blames the industry, saying that some companies raise prices “to get profits up so their executives can get better bonuses.” Dr. Karol Sikora, a prominent London oncologist, said that the institute’s math was flawed and that Dr. Rawlins had a “personal vendetta” against cancer treatments.

Drug company executives who were interviewed uniformly promised to cooperate with NICE, but industry advocates were not so kind. Robert Goldberg, vice president of the Center for Medicine in the Public Interest, an advocacy group financed by drug makers, likened Dr. Rawlins and his institute to terrorists and said their decisions were morally indefensible. . . .

Britain’s National Health Service provides 95 percent of the nation’s care from an annual budget, so paying for costly treatments means less money for, say, sick children. Before NICE, hospitals and clinics often came to different decisions about which drugs to buy, creating geographic disparities in care that led to outrage. (Such disparities are common in the United States, even for federal Medicare patients.)Now, any drug or device approved by the institute must be offered to patients. The institute has also written hundreds of treatment guidelines in hopes of improving, and making more consistent, basic medical care.

The institute has analyzed the cost-effectiveness of surgical operations, cancer screening tests and medical devices. For example, it found that drug-coated cardiac stents were worth only $450  more than bare-metal ones. In the United States, stent price differences are often far wider. . . .

. . . because of the institute, Britain’s National Health Service has been among the first to balk at paying such prices, which has led many companies to offer the British discounts unavailable almost anywhere else. 

Johnson & Johnson, for instance, agreed to charge for Velcade, another drug for multiple myeloma, only if tests showed it was effective in a particular patient. Novartis agreed to give free injections of Lucentis, a drug for age-related macular degeneration, if patients needed more than 14 shots. Dr. Rawlins said these deals were constructed by drug makers to hide from other countries the discounts offered in Britain.  “It’s a good deal for us, but I can’t see that it will work in the long run because I can’t see that others countries will be so dim as to not notice it,” Dr. Rawlins said. . . .

But the most pressing question for the industry is what influence the British institute will have in the United States. The United States already spends more than twice as much per capita on health care as the average of other industrialized nations, while getting generally poorer health outcomes.

Michael O. Leavitt, the Bush administration’s secretary of health and human services, said in a September speech that, at its present growth rate, health care spending “could potentially drag our nation into a financial crisis that makes our major subprime mortgage crisis look like a warm summer rain.”  And while there is fierce disagreement about how and whether to control drug and device expenses as part of a broader reform of the health system, many say some cost controls are inevitable. At a September device industry conference in Washington, a seminar on the issue was standing-room only and half of the questioners mentioned NICE. . . .

Wheelchair Freedom

An editorial in today's Washington Post discusses the author's years in a wheelchair and the freedom it has provided him.  Gary Presley writes,

This month I began my 50th year of riding a wheelchair through life. In case you're wondering, everything is all right down here.  That's what I found myself thinking recently as I sailed through a shopping mall. "Look, Mikey! It's magic!" a tiny girl exclaimed to an even tinier boy as she spotted me. It was a reminder that most of the creatures I greet at eye level are either small children or large dogs, two of the better examples of God's work.

What that little girl believed about my power wheelchair was true for her and true for me. It is a magical thing. This one, my seventh, I call Little Red. She is a sturdy tool, very different from the fragile roll-about I came home with from the rehabilitation center five decades ago, having been left nearly quadriplegic by polio. Little Red is 10 years old, chipped and nicked and bent, but so powerful, so reliable, that the phrase "confined to a wheelchair" is not only demeaning but inaccurate. The wheelchair is freedom. . . .

Yes, everything is all right down here, "boob-high to the world," as my wife calls the place I occupy. Of course, like almost everyone else, I ache in spots I didn't 20 or 30 years ago, and I'm always a little short of money. But I have no reason to complain. I find the world growing a little friendlier each day. Architects and builders are talking about universal design, a concept that could turn a visit to a friend's house into something other than a ramp-toting expedition. President Bush signed the ADA Amendments Act, which clarifies and broadens the definition of disability to better protect people with disabilities from employment discrimination. We're making headway in corporate America, in entertainment and in politics: more visible and accepted, a few more of us productively employed. . . .

And like other people who have evolved from being "an invalid confined to a wheelchair" to a man advocating for such important issues as MiCASSA (the Medicaid Community-Based Attendant Services and Supports Act), as I have done for the past 10 years, I cannot forget that people with disabilities are among the last awaiting full integration into society.

I am one of a group once segregated by circumstance. That's the significance of my story: that people with disabilities have made great progress in the last generation, and even though there's much left to do, especially in the realm of employment, things continue to change for the better.

But for me, rest assured: Everything is all right down here.

Broad Conscience Clause Rule from Bush Administration

The LA Times has a write-up today about the Bush administrations proposed conscience rule and its breadth.  David Savage explains,

The outgoing Bush administration is planning to announce a broad new "right of conscience" rule permitting medical facilities, doctors, nurses, pharmacists and other healthcare workers to refuse to participate in any procedure they find morally objectionable, including abortion and possibly even artificial insemination and birth control.

For more than 30 years, federal law has dictated that doctors and nurses may refuse to perform abortions. The new rule would go further by making clear that healthcare workers also may refuse to provide information or advice to patients who might want an abortion. It also seeks to cover more employees. For example, in addition to a surgeon and a nurse in an operating room, the rule would extend to "an employee whose task it is to clean the instruments," the draft rule said.

The "conscience" rule could set the stage for an abortion controversy in the early months of Barack Obama's administration. During the campaign, President-elect Obama sought to find a middle ground on the issue. He said there is a "moral dimension to abortion" that cannot be ignored, but he also promised to protect the rights of women who seek abortion.  While the rule could eventually be overturned by the new administration, the process might open a wound that could take months of wrangling to close again.

Health and Human Services Department officials said the rule would apply to "any entity" that receives federal funds. It estimated 584,000 entities could be covered, including 4,800 hospitals, 234,000 doctor's offices and 58,000 pharmacies. . . .

 

Despite the controversy, HHS Secretary Mike Leavitt said he intends to issue the rule as a final regulation before the Obama administration takes office, to protect the moral conscience of persons in the healthcare industry. Abortion-rights advocates are just as insistent that the rights of a patient come first.  If the regulation is issued before Dec. 20, it will be final when the new administration takes office, HHS officials say. Overturning it would require publishing a proposed new rule for public comment and then waiting months to accept comments before drafting a final rule.  . . .   

The HHS proposal has set off a sharp debate about medical ethics and the duties of healthcare workers. Last year, the American College of Obstetrics and Gynecology said a "patient's well-being must be paramount" when a conflict arises over a medical professional's beliefs. In calling for limits on “conscientious refusals,” ACOG cited four recent examples. In Texas, a pharmacist rejected a rape victim's prescription for emergency contraception. In Virginia, a 42-year-old mother of two became pregnant after being refused emergency contraception. In California, a physician refused to perform artificial insemination for a lesbian couple. (In August, the California Supreme Court ruled that this refusal amounted to illegal discrimination based on sexual orientation.) And in Nebraska, a 19-year-old with a life-threatening embolism was refused an early abortion at a religiously affiliated hospital.

"Although respect for conscience is important, conscientious refusals should be limited if they constitute an imposition of religious or moral beliefs on patients [or] negatively affect a patient's health," ACOG's Committee on Ethics said. It also said physicians have a "duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive services that patients request." . . .

Judith Waxman, a lawyer for the National Women's Law Center, said Leavitt's office has extended the law far beyond what was understood. "This goes way beyond abortion," she said. It could reach disputes over contraception, sperm donations and end-of-life care. "This kind of rule could wreak havoc in a hospital if any employee can declare they are not willing to do certain parts of their job," she said.

Baucus Health Plan

Ezra Klein does a terrific job providing two critiques of Senator Baucus's health plan.  He writes,    

Bob Laszewski and Richard Eskow, two health policy thinkers who I respect very much, have come to opposite conclusions on the Baucus plan. Eskow says that the plan shows the glimmers of an emergent consensus on health reform. Lazewski says that the plans is so vague on key elements like subsidy levels and the definition of "affordability" that is shows how little consensus there is. . . .

One of the Baucus plan's embedded assumptions is that Congress should not define too much. In this, it's taking a page from the successful passage of the Massachusetts reforms, which offloaded a series of thorny questions -- including the definition of "affordability" and the specific premium subsidies -- on the Connector Authority. And sure enough, Baucus's plan has a variant of the Connector Authority in the Independent Health Coverage Council (more on that here and here).

National Public Radio had a great overview of how the Massachusetts plan was working yesterday evening.  The story focused mainly on the significant shortages of primary care physicians as individuals who previously could not afford to go to the doctor are now going for care and flooding the system with new patients. 

 

   

 

Update on Children's Health Care

DemFromCt, who writes for the Daily Kos blog, provides an update from FamiliesUSA on children's health care now that we are officially in a recession.  DemFromCt highlights various news, mostly bad, from the FamiliesUSA study,

The non-partisan FamiliesUSA sums it up with this November 2008 study:

8.6 Million Children Are Uninsured

• One in nine American children (11.1 percent) is uninsured.
• The five states with the largest number of uninsured children are Texas, California, Florida, New York, and Georgia. Together, the uninsured children in these five states account for nearly half of all uninsured children in the country (48.3 percent).
• The five states with the highest rates of uninsured children are Texas, Florida, New Mexico, Arizona, and Nevada. More than 15 percent of children in each of these states are uninsured, compared to a national median of 9.2 percent.

Medicaid and the State Children’s Health Insurance Program (CHIP) Are Picking up the Slack

• Between 2006 and 2007, the number of uninsured children declined by 521,000.
• The number of children covered by private health coverage declined by 65,000.
• The number of children covered in Medicaid and CHIP increased by 954,000.

FamiliesUSA also found the majority of uninsured children come from working families with two-parent households, so another myth goes out the window. This isn't class warfare, this is everyone.

Remember, this is just the beginning. Covering kids through Medicaid and SCHIP will temporarily help kids (but not adults), and mask what's really happening as people lose insurance and can't get it back (that takes at least two years after a recession). When states start to hurt, eligibility will be cut back and/or new enrollment will be limited at the state level. . . .

Sports in Your Genes

The New York Times has a story about children being tested for which sport they will perform best in due to their genetic make-up.  It is rather sad that parents decide to test their children - whatever happened to fun rather than winning. . .  The Times reports,

When Donna Campiglia learned recently that a genetic test might be able to determine which sports suit the talents of her 2 ½-year-old son, Noah, she instantly said, Where can I get it and how much does it cost? 

“I could see how some people might think the test would pigeonhole your child into doing fewer sports or being exposed to fewer things, but I still think it’s good to match them with the right activity,” Ms. Campiglia, 36, said as she watched a toddler class at Boulder Indoor Soccer in which Noah struggled to take direction from the coach between juice and potty breaks. “I think it would prevent a lot of parental frustration,” she said.

In health-conscious, sports-oriented Boulder, Atlas Sports Genetics is playing into the obsessions of parents by offering a $149 test that aims to predict a child’s natural athletic strengths. The process is simple. Swab inside the child’s cheek and along the gums to collect DNA and return it to a lab for analysis of ACTN3, one gene among more than 20,000 in the human genome.  The test’s goal is to determine whether a person would be best at speed and power sports like sprinting or football, or endurance sports like distance running, or a combination of the two. A 2003 study discovered the link between ACTN3 and those athletic abilities.

In this era of genetic testing, DNA is being analyzed to determine predispositions to disease, but experts raise serious questions about marketing it as a first step in finding a child’s sports niche, which some parents consider the road to a college scholarship or a career as a professional athlete.

Atlas executives acknowledge that their test has limitations but say that it could provide guidelines for placing youngsters in sports. The company is focused on testing children from infancy to about 8 years old because physical tests to gauge future sports performance at that age are, at best, unreliable.  Some experts say ACTN3 testing is in its infancy and virtually useless. Dr. Theodore Friedmann, the director of the University of California-San Diego Medical Center’s interdepartmental gene therapy program, called it “an opportunity to sell new versions of snake oil.” “This may or may not be quite that venal, but I would like to see a lot more research done before it is offered to the general public,” he said. “I don’t deny that these genes have a role in athletic success, but it’s not that black and white.”

Dr. Stephen M. Roth, director of the functional genomics laboratory at the University of Maryland’s School of Public Health who has studied ACTN3, said he thought the test would become popular. But he had reservations. “The idea that it will be one or two genes that are contributing to the Michael Phelpses or the Usain Bolts of the world I think is shortsighted because it’s much more complex than that,” he said, adding that athletic performance has been found to be affected by at least 200 genes. . . .

That is my little runner in the picture - I think that he is having a great time and that is all I really care about right now.