I've moved!

There's breaking news, epiphanites! I've officially set up a new blog -- Healthy Policy over at typepad. So for all things Kate, you should head over there.
Why the move? This little blog started as an "everything" blog. As my brain got taken over by health policy, so did the site. So I decided to move the blog to a respectable home over at typepad with special plain colors.

So I hope you'll all make the move and keep coming. It's been wonderful having everyone here -- but let's face it, the new site won't be the same without you as well!

Jumpin' in

Seems like the blogosphere is having a heyday (see here, here, and here) with Tyler Cowen's assertion that he could never become a democrat because they support single payer health care. Despite his bizzare economic claims:

But since single-payer national health insurance violates every economic law known to mankind, I am again unsure how I could leap on the Democratic bandwagon.

I think it's a reasonable position.

Matt, apparently, does not:

Time to step back. As far as I can tell, the Democratic Party is not in favor of a single-payer health care system. Dennis Kucinich proposed one ("Medicare for all!") in the 2004 primaries and, as you'll recall, he wasn't a major contender. None of the other candidates did. Several of the major liberal think tanks have come up with health care proposals in the past twelve months, and none of them have endorsed a single-payer system. So as an objection to the Democratic Party this is a slightly odd one. It would be like me complaining about the Republican plan to abolish national parks -- I'm sure someone in the GOP wants to do it, but it's hardly a requirement of entry.

This strikes me as a completely false comparison.

If you feel that strongly about single payer health care, it's totally reasonable not to want to vote Democrat. Our best chances of enacting a single payer system are surely with the Democratic party. Think tank plans aside (many of which are written for their plausibility) there's a significant number of Democrats who support single payer. The vast majority of my democratic friends do. Polling suggests that 62% of Americans favor a government-run system. I don't know how many people want to abolish the national parks, but I'm sure it's miniscule. It might not be the party platform, but surely it's a larger issue than Matt makes it out to be.

What's my party-breaking issue? Choice. I will not vote major office Republican if the candidate is a strong anti-choice advocate. Take McCain. He's all sunshine and smiles for Democrats, but were he in office and enacting his ideal legislative agenda I'd be displeased, to say the least. And come to think of it, I wouldn’t vote Republican based on their health care agenda either.

Bizarre argumentation aside, if Tyler feels so strongly about single payer, then no, I would not recommend he vote Democrat.

Update: Jon's got more on the grip of single payer among Democratic leaders.

uninspired

Hey kids.

I had me a little too much fun (and too little sleep) last night and nothing's catching my eye today. Anyone want to point me in the direction of somethin interesting?

It's how we end up with Vioxx

Via Health Care Renewal, an interesting post about shifting trends in drug trial review boards. Roy Poses writes:

The articles noted that most (75%) of US drug trials are now done by commercial firms, rather than by academic researchers. In 1991, 80% of trials were done in academia. Most of these trials have been approved by commercial, rather than academic IRBs.

That's quite a turn around. In only 14 years drug trials have gone majority university run to majority privately run. This has numerous implications, from the private company's incentive to produce favorable results to insufficient research methods. Reporters visiting one test site in Miami found some questionable practices, to say the least:

Visits by reporters to a 675-bed trial site in Miami owned by SFBC International revealed the shoddy condition of its physical plant (a bathroom with "chipped white tiles [which] reeks with urine; its floor is covered with muddy footprints and paper towels.")
The reporters suggested that trial subjects are frequently poor. They may ignore study rules to forego alcohol and narcotics. Most trial participants stated that "they barely read" informed consent documents. Reporters noted that "participants in the Miami clinical trials openly talk about how they violate SFBC rules intended to protect the integrity of the research findings."

To be sure, the reporter's investigation is by no means scientific. But I don't doubt their findings. I'm sure we've all heard those radio ads for drug trials obviously targeted towards people in their early twenties. People who wait tables for a job and need an extra buck or 100. I can certainly envision many of my less responsible friends signing up for a drug trial with pot in their system, or going out drinking at night.

The informed consent language also represents a problem. If the majority of people signing up for these trials are low-income, it's likely their literacy levels are correspondingly low, and they might have trouble understanding informed consent. There's been a lot of talk over at the FDA about making drug inserts at a 6th grade literacy level, which is completely reasonable to me. Have you ever tried to read those? I enjoyed looking at them (particularly the drug molecule structure, but that's because I was pre-med for God's sake), but most people get scared off by the chemistry diagrams.

In any case, I'm quite uncomfortable with drug trials being performed on sects of the population that are in no means representative of it. Faulty trials are how we end up with Vioxx and Guidant's heart devices on the market. There's a lot of room for change over at the FDA -- we should be pushing for stricter drug trial standards, too.

More Non-Health Care Blogging

This Yahoo News piece on Generation Y and the work place is highly hilarious, especially for those of us in said generation. Says Yahoo:

"I knew what a Roth IRA was at 17. I learned about it in economics class," says Hudson, an assistant account executive in Atlanta and a University of Alabama graduate. "My generation is much more realistic. We were in college when we saw the whole dot-com bust."

I can promise you that's not typical. I only learned what an IRA is during the SS-privatization debacle, and most of my friends still don't know what the hell that is.

"Generation Y is much less likely to respond to the traditional command-and-control type of management still popular in much of today's workforce," says Jordan Kaplan, an associate managerial science professor at Long Island University-Brooklyn in New York. "They've grown up questioning their parents, and now they're questioning their employers. They don't know how to shut up, which is great, but that's aggravating to the 50-year-old manager who says, 'Do it and do it now.' "

Are we really that annoying? God, I hope not.

"The millennium generation has been brought up in the most child-centered generation ever. They've been programmed and nurtured," says Cathy O'Neill, senior vice president at career management company Lee Hecht Harrison in Woodcliff Lake, N.J. "Their expectations are different. The millennial expects to be told how they're doing."

And that's a great thing, if you ask me. Everyone needs to be told how well/badly they're doing, it imporves morale and makes expectations clear.

The bottom line is the article is 100% personal anecdote, 0% research. But I got a kick out of it -- go read if you're interested in how our generation is being stereotyped.

Joy.

Kansas School Board Approves Controversial Science Standards

Hey, the woman I voted for was one of the four against. But I guess it doesn't help when your state is full of complete nutjobs.

Yes They Can

MedPundit says:

Count me unconvinced that computerized records will be the savior of medicine. It's just managed care in another guise

Huh. That's an interesting take, I suppose, considering the most recent Health Affairs research on electronic medical records (EMRs), which revealed astonishing benefits:

Effective EMR implementation and networking could eventually save more than $81 billion annually—by improving health care efficiency and safety—and that HIT-enabled prevention and management of chronic disease could eventually double those savings while increasing health and other social benefits.

Medpundit is apparently aware of these benefits:

Yes, it's a more efficient method of storing and retrieving information. And yes, it's a method of reducing errors, although it also introduces new system-specific errors.

But then she proceeds to add this jewel:

The government's paramount goal in pushing a nationally-connected healthcare record is to be able to monitor and prescribe what kind of treatment everyone gets.

A little paranoid, no? If anything it's the insurance companies in doctor's and patient's faces trying to dictate care.

Take my Dad, for example. He broke a bone in his foot. His doctor prescribed a nifty little ultrasound machine that is supposed to stimulate bone growth. He took said nifty machine home with him from the doctor's office and began using it. Three weeks later he gets a letter from the insurance company that this device is not, in fact, covered. Care to take a guess for the cost of this little machine? (It's about 6 inches by 6 inches) $3,000.

No one at the doctor's office mentioned that insurance plans won't cover it. They just gave it to him, and now he owes three grand.

Really though, it's clear that MedPundit's concern here has nothing to do with the ways EMR might benefit her patients, only the way it might be a hassle for her.

One of my patients was enrolled in one for diabetes, but along the way he developed liver failure from cirrhosis. He was so malnourished from his liver disease that he no longer needed his diabetic medications and it was a total waste of time and money to order his diabetic labs. But, once a diabetic, always a diabetic, and I couldn't get him disenrolled. They kept bugging me and bugging me for his labs until I just did them. And every time I filled out their forms, I would write on the bottom - "patient severely malnourished from end-stage liver disease." It didn't matter.

Does that sound frustrating? Absolutely. Yet surely there are ways to turn off reminders, etc, if that's what you're concerned about. Or get involved in program development by giving a physician's input in ways to make HIT systems physician-friendly.

It's one thing to oppose the cost of implementing EMRs and HIT (health information technology) advances, which is why the government is leading the charge (see the VA and recent grants for practices to buy HIT software). I'd like to think things like EMRs could help patients avoid problems like my dad's (i.e. the doctor or nurse having a message pop up when they type in a treatment that this patient's insurance does NOT cover this treatment). Of course, if there's only one insurer we take out the guess work.

Medpundit's opposition to HIT exposes a selfish concern for the amount of hassle in learning a new system. I could go on about Medpundit's attitude, but I think her post should make those designing HIT think twice. If we can't come up with user-friendly systems, widespread use of EMR's will remain a fantasy. There are many, many reasons the medical community should support these technological advances. They will reduce their (or their nurse's, or other doctor's) errors, and help make their patients healthier. Don't doctor's with similar view to Medpundit complain over and over about malpractice insurance fees? EMR's offer a much better (and logical) fix than tort reform. Not to mention $81 billion a year in savings.

Reformers have decades of physician interference to learn from -- we've got to make sure system bugs and complicated interfaces don't become the focus of the AMA's next crusade.

Hat tip to Graham for the link.

South Africa , or what we could become

I know there's been a lot of talk on Consumer Directed Health Care (CHDC) on this site lately. I'm going to continue on that meme today, because there's some fundamental issues worth considering if we're going to continue down that road (we're already on it, you can be sure of that).

David Adler over at The New Republic has an interesting piece on Consumer-directed health care in South Africa. Basically about half of the country's privately-insured are enrolled in high deductible plans. But the introduction of HDHPs (high deductible health plans) has had some unanticipated side-effects:

The result was an unprecedented restructuring of the insurance market. The young and healthy migrated to the new consumer-driven plans and away from traditional employer-based schemes. Meanwhile, the old and infirm were left in traditional insurance schemes.

That seems like a predictable response, right? Is it really such a big deal to have insurance segmented in this way?

The answer is, absolutely. Health insurance in the U.S. went through a massive restructuring after commercial insurers switched to experience rating and drowned Blue Cross in the 1950's. Blue Cross had offered moderately priced health plans to all workers through community rating, but other commercial insurers could offer cheaper plans to select groups of individuals through experience rating. The inevitable result was that all the young and strapping moved over to cheaper plans while the old and infirm had to stay with Blue Cross. Stuck with a bunch of high-cost patients, Blue Cross had no choice but to switch to experience rating as well. Which they did.

Now South Africa has experienced the same thing, except this time it was brought on by HDHPs. It's reasonable to believe the same could happen here as well as more and more people enroll in HDHPs. If that's the case, all these plans are going to do is cause a fundamental restructing of health insurance as more and more people are sectioned off according to their health status. Again.

And what's worse?

At a macroeconomic level, however, there is less cause for celebration. Private health care costs have hardly been contained. In fact, the opposite is the case. Between 1996 and 2001, the cost of specialty care increased 43 percent, and the cost of hospital care rose 65 percent. This represents a marked increase from the inflation rates for the five years prior. There have also been substantial increases in plans' administrative costs.

It's a temporary fix. Look at the graph again. Why, after forty years of trying these different private market solutions, should we believe it's going to be any different this time?

Especially when another country has proved exactly what we fear.