With apologies to GE, Disney and the 8 US citizens who remain optimistic about prospects for our health care system.

Welcome to the US Health Care Carousel of Progress!

Normal carousels just spin ’round and ’round and don’t get you anywhere, but ours is different.

The Health Care Carousel makes progress every year.

And progress isn’t simply moving forward, it’s working together and dreaming and assuring better health care for all.

Progress is the whiz-BANG of an MRI machine in use for the evaluation of a 22 year old with a headache. It’s the drug-induced smile on the face of a woman that became depressed after losing her home to foreclosure.

Progress is the rhythmic lub-dupp of a heart beating normally following a transplant for preventable cardiac disease. It’s the sound of an uninsured child wheezing in a crowded emergency room.

Why, you can hardly imagine all the amazing gadgets they’ve got in ERs nowadays!

Remember the sixties when folks got their exercise doing the Twist? Well, today we keep our cholesterol down with pills!

And our food safety system has never been better.

Our generation may be the first in 300 years to experience a decrease in life expectancy, but think how much worse it would be without $10,000 cancer drugs and blood thinners that prevent complications from hardware we’ve inserted into people’s bodies.

It’s never been easier to find a PCP, and would you believe it? They’re building our city’s 17th PET scanner right where that run-down urban health clinic used to be.

You should hear physicians rave about how those newfangled EMRs save them time.

And progress even has a smell! It’s the smell of money lining the pockets of a hundred-thousand physicians that have been bought off by Big Pharma.

With all these marvels, it’s hard to believe things could get better than they are right now. But as you join us for a spin around our Carousel of Progress, you’ll surely agree. Anything’s possible.

Ethics
In a referenced essay titled, Transparency in the Pharmaceutical Industry, Brain Blogger’s Jennifer Gibson describes how the impending passage of the Physician Payments Sunshine Act has motivated Big Pharma to disclose financial relationships with physicians. She warns there may be adverse consequences from this otherwise laudable development: some physicians will be discouraged from forging socially beneficial collaborations with the private sector.

Last week, the FDA’s Psychopharmacologic Drug Advisory Committee unanimously rejected AstraZeneca’s application to market its atypical anti-psychotic drug Seroquel for generalized anxiety disorder and major depression.

Merrill Goozner at GoozNews applauds the decision, but wonders whether the agency may have left itself open to charges of bias by seating a patient representative on the panel who had lost a son to cardiac arrest while taking the drug. 

Health Care Renewal contributor Roy Poses has reviewed an unseemly side show to the Madoff scandal. The antagonist is Ezra Merkin, a hedge fund director charged with fraud for misrepresenting his investment strategies.

Merkin and Madoff had served on the board of Yeshiva University, which lost $110 million to the Ponzi scheme. Their unholy alliance leads Poses to consider possible negative consequences of having too many financial types on the boards of academic institutions.

Insurance
In the latest chapter of her neverending odyssey to navigate Big Insurance and the health care system generally, Colorado Health Insurance Insider’s Louise Norris describes what happened when her husband needed knee surgery. The savvy couple planned for every contingency, yet still they encountered a system failure in the form of an out of network charge.

Jaan Sidorov at Disease Management Care Blog has proposed a frightening, unintended consequence of health care reform which is that private health insurers might, like AIG, become too big to fail.

Sidorov thinks creation of a new public insurer will prompt a wave of consolidation in Big Insurance, and the remaining behemoths will seek cover in the form of regulatory oversight from the Feds.

Over at The Health Care Blog, Brian Klepper has contributed a wide-ranging historical perspective on efforts by Big Insurance to control health care cost escalation.

After characterizing utilization review and PCP gatekeeper systems as well-intentioned but poorly executed efforts, he proposes that tricked-out workplace-based clinics (“onsite clinics”) may be a solution, and cites facilities on the premises of Cigna as shining examples.

He concludes however, that the proof will be in the pudding. After all, everyone thought UR and gatekeepers were good ideas, too.

There’s a great, big, beautiful tomorrow,
Shining at the end of every day

There’s a great, big, beautiful tomorrow
And tomorrow’s just a dream away

Man has a dream and that’s the start
He follows his dream with mind and heart

When it becomes a reality
It’s a dream come true for you and me

Access, Cost Escalation
InsureBlog’s Bob Vineyard reviews interim results from Massachusetts’ much publicized universal health care plan, which many believe should be a model for national health care reform.  The plan has left at least 200,000 state residents uninsured while utterly failing to rein in costs. And to make it right Vineyard warns, Bay state lawmakers are either going to have to squeeze providers even more or (gasp!) ration care.

At Managed Care Matters, Joe Paduda has posted a dispassionate, fact-based treatise designed to calm the knee-jerk anxiety that normally surrounds concepts like universal health care and rationing.

He points out for example that Big Insurance already engages in rationing through pre-certification processes, provider agreements and so forth.

He then dismantles the claim that universal health care leads to longer waiting times for care. Paduda concludes that if we manage to institute such programs, “access will go up and waiting times may well go down.”

Amid a fusillade of jabs and an occasional uppercut to the jaws of the Big O and his admirers, JD Bell reveals over at It Takes Work that Howard Dean has launched a web site to promote his own vision for health care reform.

According to Bell, Dean is concerned the Big O is waffling on his campaign promises, and wants nothing more for the American people than what Obama promised them prior to November 4.

Writing for Workers’ Comp Insider, Jon Coppelmen observes that employers’ most effective tools for managing comp losses vanish after they lay off employees. The trust, indeed the entire relationship between employer and former employee, is lost. This leaves claims adjusters, who are typically overworked and not properly incented, to manage workers’ compensation costs.

With unemployment approaching historical levels, Copplemen’s antidote, three proactive steps employers can take to manage the regrettable situation, is timely indeed.

Quality and Safety
A recent NEJM article on the cost and quality implications of readmissions has prompted Maggie Mahar to review the subject over at Health Beat. Mahar summarizes the views of White House budget director Peter Orszag and others on the matter, and then offers several home-grown suggestions about how to tackle the problem.

Mahar explores for example, the concept of bundling payments to hospitals and physicians who are responsible for care immediately following discharge, and directing special attention towards states in which the readmission problem is particularly severe.

Novo Nordisk had been prepared to discuss cardiovascular complications at last week’s FDA advisory panel meeting regarding liraglutide, its new diabetes drug, but instead the drug’s association with rare tumors of the thyroid drove the discussion.

Jeffrey Seguritan at Nuts for Healthcare summarizes the surprising development then expands into an informative discussion of the efficacy with which drug trials assess cancer risk.

There’s a great, big, beautiful tomorrow,
Shining at the end of every day

There’s a great, big, beautiful tomorrow
And tomorrow’s just a dream away

Man has a dream and that’s the start
He follows his dream with mind and heart

When it becomes a reality
It’s a dream come true for you and me

Legal
HealthBlawg’s David Harlow is generally supportive of the deal struck by CVS and Google, in which prescription data from the retail pharmacy giant can now be directly imported into Google Health, the search giant’s personal health record. On balance Harlow says, the gains in patient safety and quality outweigh the increased risk of breaches in patient confidentiality, at least for people who have not recently given birth to octuplets or are named Britney Spears.

Health IT
When a healthcare journalist came down with a touch of bronchitis, he blew off the last vendor meeting at HIMSS and went to the doctor.

His encounter underscored a yawning gap between today’s reality of spotty EMR adoption and a future-state of nirvana that has been promised by so many. 

The real-life story appears at Niel Versel’s Healthcare IT Blog.

We hope Neil feels better, by the way.

At the Health Business Blog, David Williams has posted a transcript of his interview with Wayne Guerra, the co-founder and chief medical officer of Healthagen, the maker of a way-cool iPhone application known as iTriage.

In the interview, Guerra explains how his mobile triage and health information tool can be used, the types of people most likely to benefit from it, and how he hopes to monetize the idea.

The Healthcare IT Guy invited Paul Nuschke, a software design expert at the IT consultancy Electronic Link to comment on the subject of EMR usability. Nuschke asserts there are three keys: the EMR should be easy to learn, efficient, and prevent errors automatically.

Nuschke appends a series of baffling screen shots which make it laughably clear that some of the mainstream players in the space aren’t quite there yet.

Policy
Over at the Healthcare Economist, Jason Shafrin asks, “Why have disability rates decreased?” To answer the question, Shafrin reviews a scholarly piece from the National Bureau of Economic Research. He notes that the apparently heartening trend has occurred despite an increasing burden of illness in the general population. The beneficial trends, he concludes, are attributable primarily to non-medical advances like “internet shopping, amplifying devices for phones and street ramps” rather than health care-specific interventions.

Damn, we thought we had something there for a moment.

Actual US Health Care Carousel of Progress:

In the US, utilization of CT and MRI scanning increased 43% between 2002 and 2007 to 96 million procedures. PET scanning tripled over the same period.

Americans did not get sicker during this time, nor had the medical community been inundated with evidence suggesting the tests were underutilized beforehand. In fact before the most recent imaging fiesta began, experts had estimated that 30% of all scans were unnecessary.

The drivers of inappropriate scanning haven’t changed in 30 years. Patients want the reassurance. Physicians want protection from litigation and sometimes, physicians benefit financially from the tests they order.

This state of affairs is unacceptable for two reasons. First, the scans can cause harm, either by direct radiation exposure in the case of CT, or by obligating risky invasive interventions to track down false positive results. Second, imaging tests are expensive. It costs $228 dollars for a CT scan, $977 for an MRI and $2,000 for a PET.

Health care providers see themselves as guardians of the quality of care, but for the most part their efforts to do so are patchwork and ineffective. There are some guidelines, an occasional implementation strategy, a performance measurement system or two, and a rare link between pay and performance, but the whole thing doesn’t add up as the above statistics suggest.

Yet they howl like coyotes when payers hire radiology benefits managers, known lovingly in the industry as Radiology Police, to oversee the matter. No less than three such organizations, CareCore National, American Imaging Management and National Imaging Associates turn a profit doing just that.

Those profits are a measure of waste in the US health care system.

The situation begs for providers to take ownership of the situation, and now for the first time they have the tools to do so. Plenty of good guidelines are available and EMR systems that support real time, guidelines-based quality checks give providers an unprecedented opportunity. We can do this, guys!

On July 20, 1969, Camp Equinunk watched man land on the moon through an 11-inch black and white TV that was getting a lousy signal from Scranton.

No one cheered. There wasn’t much talk. It was personal experience, shared collectively. It was absurd, overwhelming. Could this be happening?

But Neil Armstrong had prepared for his moment. He must have practiced his line a hundred times before hopping off the LEM.

And yet there it was, unmistakable! An ever-so-slight hesitation after the first word that completely and totally humanized the moment, “That’s…one small step for man, one giant leap for mankind.” 

So the event happened. We did it! A moment of great pride!

Last night, the TV picture was large, crystal clear and in color, but that didn’t make it easier for the brain to believe what the eyes and ears said must be true.

It took a once-in-a-century economic crisis and a historically inept predecessor. It took a candidate who never got too high or low during a perfectly executed 2-year push. It took an entire generation of young voters and millions of others who voted for the first time and it took a lot more than all of that for Barack Obama to win a national election by 5 percentage points.

Five.

But win it he did. In years to come we’ll see replays of Obama’s confident stride towards 100,000 greeters in Chicago. We’ll hear the speech. We’ll watch him embrace his family, running mate and close friends. We’ll watch the group drift behind the curtains and flags, and we’ll find plenty of humanizing moments.

But right now what I remember is that the Big O didn’t flinch, not once. The smile, the wave, that angular posture of his, it was all so true. Barack Obama stood there as the President elect, and the moment was not too big for him.

It happened. We did it! We really, really did it.

Controversial VP pick Sarah Palin didn’t just lance a festering boil of Republican angst last night. She dazzled. She was poised, self-assured, in command and not only that, she was accessible and likable.

She proved to be pretty adept with a shiv, too  (“I have actual responsibilities”).

To be sure, hers was an easy test-she read a speech (more about that shortly) before a crowd that desperately wanted her to succeed. Going forward, we’re likely to see her in similarly controlled situations as she takes time to brush up on her world maps and McCain’s changing policy positions.

Tougher tests will come when she faces the media or her opponents. There is also the risk that a story or two about her Alaska shenanigans will grow legs.

Still, Sarah Palin did save the game for McCain and his party, at least for one night. That was impressive! Congratulations to her.