Spend Billions More on HIT When Public-Health Services Get Crunched by Budget Woes?

I have the answer to these cutbacks of pubic health services.

In the midst of economic chaos, let's spend tens of billions or even better, hundreds of billions of dollars more on experimental healthcare IT.

(It worked out so well for the UK's NPfIT, we should follow the NHS's example of how to wisely spend our crucial healthcare billions.)

I will comment no further:

Wall Street Journal Health Blog
October 5, 2011, 10:00 AM ET
Public-Health Services Get Crunched by Budget Woes
By Betsy McKay

Immunizations, emergency preparations for hurricanes, and restaurant inspections are among local public-health services being cut back or eliminated amid budget constraints.

Some 55% of the nation’s county and city health departments reduced or eliminated at least one program between July 2010 and June 2011, and the public-health workforce continued to shrink, according to a new survey by the National Association of County and City Health Officials.

The cuts hit maternal and child health services (at 21% of the departments reporting cuts), personal health services (20%), emergency preparedness (20%), chronic disease screenings (17%), and food safety (11%), among other programs.

Health departments lost 5,400 jobs in the first half of this year, after losing 6,000 in all of 2010. There are currently about 120,600 local health department employees across the country after those cutbacks. While the workforce has been shrinking since 2008, the downsizing “is now eating into program capacity,” says Robert Pestronk, NACCHO’s executive director.

Particularly worrying are the cutbacks in emergency-preparedness programs, he says. “It’s troublesome given what we’re seeing in terms of weather conditions and threats in communities,” he tells the Health Blog. Health-department employees help plan for emergencies such as hurricanes, make sure supplies are in place and work as responders.

Meantime, cutbacks in immunization programs are making it harder for some children to get needed polio, tetanus and other preventive vaccinations, while reductions in food-safety programs mean fewer restaurant inspections or staff to interview people sickened in a food-borne illness outbreak, Pestronk says.

These woes aren’t limited to local health departments. The Centers for Disease Control and Prevention has seen its budget for preparedness and response fall by more than $350 million since 2005, to about $832 million in fiscal 2011. That challenges the CDC’s ability to respond to a pandemic like the type featured in the recent bio-thriller “Contagion,” Rear Admiral Ali Khan, the CDC’s chief of public health preparedness and response, told the Health Blog at a screening of the film.

Also see my March 2010 post "Hospitals Under the Knife: Sacrificing Hospital Jobs for the Extravagance of Healthcare IT?" where I observed:

... In effect, NY hospital physicians, nurses and support staff will lose their job due to budget shortfalls, at the same time the NY hospitals have been spending hundreds of millions of dollars on the extravagance of experimental clinical IT systems whose benefit is still an unknown.

Perhaps some of those millions could have been better spent on human beings, such as employees or better yet, patient care.

-- SS

Exporting the US "Health Ecosystem" and its "Wonderful Technology, Wonderful Approaches," or Exporting "A Parasite Eating Its Host?"

Last week, an article in the Minneapolis Star-Tribune suggested that our US corporate health care giants think they are doing such a good job they want to export the "world's best health care system" overseas:

A coalition of U.S. health care businesses, including Minnesota-based UnitedHealth Group and Medtronic, proposes to rebuild America's battered economy by selling the country's 'health ecosystem' internationally.

The Alliance for Healthcare Competitiveness (AHC) wants the U.S. government to build its foreign free-trade policy around the health care industry, noting that the sector has been a significant jobs creator since the recession began in 2008. Breaking down tariffs and other forms of international discrimination against America's 'health ecosystem' will allow developing countries such as China, India and Brazil to improve medical care while allowing U.S. companies to rescue the American economy by hiring more people, AHC leaders said Monday.

The worldwide need for health care in aging populations will lead to a demand for goods and services that can drive sales of American insurance, medical devices and record-keeping technology, said Simon Stevens, UnitedHealth's president of global health and an AHC member.

AHC members seem really convinced of the value of what they have to sell:

'We've got a lot of wonderful technologies, wonderful approaches,' said Alex Gorsky, Johnson & Johnson's vice chairman.

The Star-Tribune did note that our "health ecosystem" is

beset with skyrocketing costs and inefficiencies. Americans currently pay more for health care and rank lower in life expectancy and infant mortality than much of the developed world.

The article also managed to find one slightly dissenting expert,

'It seems ironic, at best,' said Jean Abraham, a professor of health policy and management at the University of Minnesota

Let me add a little more irony. The AHC advocates are top leaders at UnitedHealth and Johnson and Johnson.

UnitedHealth Group's Sorry Record

UnitedHealth would be the company whose CEO once was worth over a billion dollars due to back dated stock options, some of which he had to give back, but despite all the resulting legal actions, was still the ninth best paid CEO in the US for the first decade of the 21st century (look here). UnitedHealth would be the company whose current CEO made a cool $106 million in 2009 (look here). Howver, UnitedHealth would also be the company known for a string of ethical lapses:
- as reported by the Hartford Courant, "UnitedHealth Group Inc., the largest U.S. health insurer, will refund $50 million to small businesses that New York state officials said were overcharged in 2006."
- UnitedHalth promised its investors it would continue to raise premiums, even if that priced increasing numbers of people out of its policies (see post here);
- UnitedHealth's acquisition of Pacificare in California allegedly lead to a "meltdown" of its claims paying mechanisms (see post here);
- UnitedHealth's acquisition of Sierra Health Services allegedly gave it a monopoly in Utah, while the company allegedly was transferring much of its revenue out of the state of Rhode Island, rather than using it to pay claims (see post here)
- UnitedHealth frequently violated Nebraska insurance laws (see post here);
- UnitedHealth settled charges that its Ingenix subsidiaries manipulation of data lead to underpaying patients who received out-of-network care (see post here).
- UnitedHealth was accused of hiding the fact that the physicians it is now employing through its Optum subsidiary in fact work for a for-profit company, not directly for their patients (see post here).

Johnson and Johnson's Sorry Record

Johnson and Johnson also would be the company known for recalling heroic numbers of products, 26 different recalls since 2009, the latest, of Eprex, two weeks ago (see the WSJ Health blog recall watch here.).

Johnson and Johnson also has an amazing recent record of ethical lapses and guilty pleas, including:
-  Convictions in two different states in 2010 for misleading marketing of Risperdal
-  A guilty plea for misbranding Topamax in 2010
-  Guilty pleas to bribery in Europe in 2011 by J+J's DePuy subsidiary
-  A guilty plea for marketing Risperdal for unapproved uses in 2011 (see this link for all of the above)
-  Accusations that the company, which makes smoking cessation products,  participated along with tobacco companies in efforts to lobby state legislators (see post here)
-  A guilty plea to misbranding Natrecor by J+J subsidiary Scios (see post here)

With the justification that "he met expctations," so despite, or maybe because of all this, Johnson and Johnson paid its CEO $29 million in 2010 (see post here).

Summary
 
So maybe UnitedHealth Group and Johnson and Johnson want to quickly export their brilliance before someone else realizes how bad their corporate records are, and takes action in response.  Note that the "international discrimination" against such companies noted above could simply be another description of better regulatory systems in other countries which are more able to defend against the sorts of sleazy behavior that has plagued US health care.  If US "free-trade" policy succeeds in challenging such regulation, other developed countries, which provide generally better health care at lower costs, could become more susceptible to catching the US health care dysfunction syndrome.
 
For more pithy comments, Minneapolis Public Radio published a commentary by David Durenberger in which he noted:

A physician I know read a story in Tuesday's newspaper at about the same time I did, 6 a.m. By 8 we'd found that we were having identical reactions to this absurdity. But he had a better way of expressing it: 'It's like a parasite eating its host.'

'They have bankrupted our culture, so now they want to try and bankrupt China and India,' he said.

Of course, if maybe we could export all of Johnson and Johnson, UnitedHealth Group, and other corporations with similarly bad records of crimes, legal settlements, ethical missteps, and bad leadership to India and China, maybe our health care system would start recovering from its dysfunction (but then pity the poor Chinese and Indians).

Maybe the corporate leaders quoted above suffer from the same apparently complete lack of insight that another health care CEO (actually former CEO) exhibited recently (look here). However, such glaring inability to perceive one's own problems surely will lead them to grief in the near future. Our corporate health care giants have already lead our dysfunctional health care system to enough grief.

True health care reform would favor leaders of health care organizations who understand the health care context, and uphold health care professionals' values, and have enough insight to realize when they are falling short of these standards.

Meanwhile, rest assured that US health care is the system where nothing can go wrong, go wrong, go wrong.

How the Rich and Influential Get Health Care Different from You and Me: Data About How Very Influential Persons Get Expedited Care

An MSNBC story summarized some new data about how at least a particular subset of the rich can get different health care from you and me:

Expedited Care for the Influential

In a letter published in this week’s Annals of Emergency Medicine, Dr. A.J. Smally of Hartford Hospital and the University of Connecticut reports that more than half of the 33 emergency department medical directors in his state said they routinely provide so-called 'expedited' care to influential people.

The influential people here include "corporate donors, hospital administrators, or, say, the brother-in-law of the president of the board of directors."

This was corroborated by "a survey of 100 emergency doctors nationwide" which showed that "84 of them had given or would given extra attention to an influential person, such as a famous person or a hospital donor."

Dr Smally asserted, "emergency triage protocols mandate treating the sickest patients first, no matter their social status." However, he also acknowledged that influential people will get treated more quickly,

'Somebody calls and says so-and-so is coming in, can you make sure they get good care,' Smally said. 'We bump them up a notch. If everyone is waiting four hours, they might just wait one hour.'

Better "Hotel Services"

The article also noted that influential people are likely to get better "hotel services" from hospitals, presumably at no extra cost to them:

to the head of the Association for Healthcare Philanthropy, a 5,000-memeber organization dedicated to boosting donations, tending to contributors when they’re sick or injured is just part of doing business.

'It is true, we pay attention to our donors,' said Bill McGinly, president and CEO of AHP, who says most development departments are alerted when VIPs enter their hospitals. 'They’ve gone above and beyond. We recognize that their contributions can make a difference to the community.'

In some cases, that care can border on coddling. At Norwalk Hospital in Norwalk, Conn., donors who contribute $100,000 or more are known as 'Navigators' who receive not only a place at the front of the line, but top-tier attention as well.

'We help the family in any which way that we can,' said Carol Brennan-Smith, communications manager for the Norwalk Hospital Foundation. 'If their cell phone has no juice or they need a battery charger. It can be ‘I want lemonade, I want a Ben and Jerry’s Cherry Garcia ice cream.’ If we can do it, we will.'

Grumbling and a Little Dissent
The ER docs involved also seemed unwilling to question the practic, although they did not seem perfectly comfortable with it:

grumbling is common, but to Smally and other ED docs, there’s little moral dilemma. Dr. Michael Carius, chair of the emergency department at Norwalk Hospital, home of the 'Navigators,' said he’s confident that no one is harmed by the practice — and that it actually may wind up doing greater good.

'This is a way of building good will so that when there is a need the hospital has, there’s this favor bank,' he said.

The article only noted briefly that not all would agree with him:

ethicists and patient advocates worry that improved access for VIPs undermines the public mission of community emergency rooms and raises sharp questions about health care equality.

'It’s not fair at the micro-level and I’m not sure it’s fair at the macro-level,' noted Laura Weil, former director of the Health Advocacy Program at Sarah Lawrence College in Bronxville, N.Y.

In my humble opinion, the data and anecdotes summarized in the article raise a host of issues that deserve further thought.

Can the Self-Interested Be Donors, and Should They Receive Favored Treatment from the Government?
First, let us address the issue of donors receiving better "hotel services." I am not sure there are problems with offering better hotel services, as long as they have no direct effect on medical care, for a price to anyone who is willing to pay.

However, the article suggests that the donors receive special services that might not be available to anyone else, even for a price. If so, that challenges their claim to be donors. Donation implies a lack of self interest, and is honored socially, and financially by the US Internal Revenue Service in the form of a tax deduction. If donors are receiving special consideration in return for their donation, their donations may actually be self-interested means to get services they could not buy on the open market, and do not deserve honor.

Even if the donation was given expecting a partial quid pro quo in the form of a service that could otherwise be obtained by others for a price, to the extent that the donations included money paid for services, they may not deserve tax deductions. If the hospitals did not report the donation less the price of the services received in exchange for it, or if the donors did not subtract this amount from their donation before deducting it from their taxes, it might be worth an IRS investigation, perhaps both of the hospitals' non-profit status and the donors' personal tax returns.

I hope the IRS is paying attention to this issue.

Is It Ethical to Give Patients Who Are Not Donors Slower Care for Acute Illnesses?

A much bigger problem is the data suggesting donors, hospital executives, and their relatives may get not only cushier hotel services, but more rapid emergency department care.  Since emergency departments are often operating near capacity, this rapid care for some may mean slower care for others.  In many cases, slower care means more pain, more suffering, more morbidity, and in certain cases, a higher likelihood of dying.

Physicians have an ethical obligation to put each patient's interests ahead of other concerns (like attracting more donations to the hospital). It seems unethical to me to put a less sick patient ahead of a more sick patient because the former is an influential person.

Knowing that sick patients sometimes get delayed care to make way for a VIP may open a whole new area of legal discovery for plaintiffs' lawyers seeking to litigate against hospitals when patients suffer from slow care in the Emergency Department.

I hope plaintiffs' attorneys are paying attention to this issue.

There may also be legal issues for hospitals if the law requires them to make emergency care available to all acutely ill patients. If some hospitals delay emergency care for some acutely ill patients to provide expedited care for some less acutely ill patients because they are influential, there may be legal ramifications.

I hope the US Department of Justice, state attorneys general, and state departments of health are paying attention to this issue.

Does Insulating the Rich and Powerful from the Dysfunctional Health Care System Make for Bad Health Care Policy?
Finally, there is a larger health policy issue. At least a few of my fellow health care dissenters has been known to grimly opine that no real health care reform will take place until some big-wig, or his or her child, spouse, lover, sibling, or parent gets really bad care at the hands of our dysfunctional health care system. However, it appears that the rich and powerful have found ways to make this improbable.

In a number of ways, the rich and powerful have found ways to engineer a deluxe health care system for themselves. We have posted how big corporate executives have access to "executive health insurance" which provides benefits beyond what any normal person can obtain, even from seemingly the best employer paid policy. In 2007, we posted about how one academic medical center had an "A-list" of influential people who got special amenities and more rapid care. Now there is data to suggest this may be common practice.

If the rick and powerful can insulate themselves from the dysfunction of the current health care system, do not expect their sympathy or support in reforming this system. It appears that to truly reform health care, we will have do something about the context, call it a new gilded age, new age of the robber barons, oligarchy, plutocracy, or age of crony capitalism, in which it exists.

The Case for the Food Reward Hypothesis of Obesity, Part I

Introduction

When you want to investigate something using the scientific method, first you create a model that you hope describes a natural phenomenon-- this is called a hypothesis.  Then you go about testing that model against reality, under controlled conditions, to see if it has any predictive power.  There is rarely a single experiment, or single study, that can demonstrate that a hypothesis is correct.  Most important hypotheses require many mutually buttressing lines of evidence from multiple research groups before they're widely accepted.  Although it's not necessary, understanding the mechanism by which an effect occurs, and having that mechanism be consistent with the hypothesis, adds substantially to the case.

With that in mind, this post will go into greater detail on the evidence supporting food reward and palatability as major factors in the regulation of food intake and body fatness.  There is a large amount of supportive evidence at this point, which is rapidly expanding due to the efforts of many brilliant researchers, however for the sake of clarity and brevity, so far I've only given a "tip of the iceberg" view of it.  But there are two types of people who want more detail: (1) the skeptics, and (2) scientifically inclined people who want mechanism.  This post is for them.  It will get technical at times, as there is no other way to convey the material effectively.

Read more »

The Case for the Food Reward Hypothesis of Obesity, Part I

Introduction

When you want to investigate something using the scientific method, first you create a model that you hope describes a natural phenomenon-- this is called a hypothesis.  Then you go about testing that model against reality, under controlled conditions, to see if it has any predictive power.  There is rarely a single experiment, or single study, that can demonstrate that a hypothesis is correct.  Most important hypotheses require many mutually buttressing lines of evidence from multiple research groups before they're widely accepted.  Although it's not necessary, understanding the mechanism by which an effect occurs, and having that mechanism be consistent with the hypothesis, adds substantially to the case.

With that in mind, this post will go into greater detail on the evidence supporting food reward and palatability as major factors in the regulation of food intake and body fatness.  There is a large amount of supportive evidence at this point, which is rapidly expanding due to the efforts of many brilliant researchers, however for the sake of clarity and brevity, so far I've only given a "tip of the iceberg" view of it.  But there are two types of people who want more detail: (1) the skeptics, and (2) scientifically inclined people who want mechanism.  This post is for them.  It will get technical at times, as there is no other way to convey the material effectively.

Read more »