Is Lifespan Merger Good for Our District?

Is Lifespan Merger Good for Our District?

From the Boston Globe:

You just have to pay it, Steve," Sam Thier, the likable but combative former chief executive of Partners HealthCare, the 800-pound gorilla of the Boston online pharmacy viagra world, used to tell me when I'd ask, as I often did, about the exploding cost of healthcare.
"Of course, you have to pay," says Regina Herzlinger. "The question is how much?"
That is a good question with both Mass. & R.I. (with Lt. Gov. Robert's proposed program beginning to wend its way through the Lege) attempting to answer it. But there is also a more central question that needs to be broached and it is even more difficult to answer. How do we control soaring double-digit costs, most notably in meds & hospital charges which control insurance costs?


Herzlinger lays out her case for another way in her provocative book, "Who Killed Health Care?" which is nothing short of an all-out attack on the "villains" of the current system, including the hospitals, the insurers, and Congress.
What especially caught my eye was her statement regarding the Boston hospital market: "Whenever there is oligopoly in any industry, it is no good. It cannot be good."

In R.I. this could become much worse with Landmark's proposal to merge most area hospitals. While this could work out quite well for them, it's questionable as to the effect on we the consumers. One large company would control most all of our hospital health care system. Forget oligopoly & think monopoly.

The mergers [in Boston], she says, have accomplished their goals: limiting competition and raising prices. Hospitals now hold leverage over the insurers.
Oh, goody. This merger is something that we all should be keeping our eyes on. At some point in time there will be public hearings on it. I don't mind paying for healthcare and I doubt anyone does. The question is how much & when will we just get tapped out by uncontrolled costs? The book's author suggests consumer-driven healthcare reforms is one answer. She wants more data from the hospitals themselves so that one can compare.

A good idea actually, but how much more can I be expected to take ownership of? An example would be the bill for R.I. hospitals to reveal to the Dept. of Health their infection rate AFTER entering the hospital. These infections are the nation's fourth highest killer & are often preventable with better hospital cleanliness outside the operating rooms. Lifespan objected because it was concerned over how the data would be used. I support this bill as it's we the people who basically support hospitals. We have the right to know period. The bill was "held for futher study" which essentially means that it's dead.

Most times I have been to the hospital there really was little choice on my part. Which was closest, which did the procedure and which had the bed doesn't directly speak much to what she's looking for but it's central to me. Frankly competition in this area doesn't seem to work that well compared to which computer do I want to purchase.

America spends $2.1 trillion a year on healthcare, about the size of the Chinese economy. This week the federal government projected that number will double to $4 trillion in a decade. Hospital spending, representing roughly 30 percent of all healthcare spending, was again the fastest-growing sector.
....Another way to think about it is in competitive terms: America spends about
16 percent of its gross domestic product on healthcare; Japan spends about half
that. That difference explains, in part, why Toyota is crushing General Motors.

This is a good argument for universal healthcare with a single payer system. Yes, I don't mind paying but my wallet isn't bottomless. Trusting the hospitals & med companies to monitor themselves with market forces controlling them doesn't seem to be working very well, does it? The Europeans and Canadians have more experience with this & have been quite sucessful. We need to look to them for models & learn from them.

Check out "Who Killed Health Care?" at the library or book store. Editorial reviews of this good. And keep your eyes on that proposed merger. Real-life "Monopoly" is going to take a lot to convince me. And, yes, Newport Hospital is in this District.

ISBN-10: 0071487808

Thanks to Globe columnist Steve Bailey.

Men’s Health? Women’s Health? Valid screening opportunities or “Hallmark Holidays&

Men’s Health? Women’s Health? Valid screening opportunities or “Hallmark Holidays”?

. This blog has previously discussed the use of PSA as a screening tool for prostate cancer (March 21, 2009: PSA Screening: What is the value?, and a guest column by Robert Ferrer, MD MPH in October 27, 2009: PSA Screening: “One of Medicine's Great Success Stories"? ), and indicated that it was not only a poor test, but a dangerous one, leading to unnecessary biopsies, diagnosis of disease that was unlikely to progress and treatment that would probably not change the outcome but would almost certainly lead to significant morbidity. A new study by Vickers, et al., published in the Journal of the National Cancer Institute (An Empirical Evaluation of Guidelines on Prostate-specific Antigen Velocity in Prostate Cancer Detection, JNCI, doi: 10.1093/jnci/djr028, first published online: February 24, 2011), shows that the use of “PSA velocity” as a screening test for prostate cancer, is flawed and not a valid indicator. PSA velocity refers to the rate of change (presumably, increase) in the level of prostate-specific antigen (PSA) over time; the theory, which this study demonstrates to be invalid, is that the faster the rate of rise (velocity), the more likely someone is to not only have prostate cancer, but to have aggressive cancer needing intervention. In fact, the study shows that “Biopsying viagra with high PSA velocity but no other indication would lead to a large number of additional biopsies, with close to one in seven cheap cialis being biopsied….We found no evidence to support the recommendation that men with high PSA velocity should be biopsied in the absence of other indications; this measure should not be included in practice guidelines.” And so another effort to find a way to use PSA to diagnose prostate cancer, like “highly sensitive PSA” before it, bites the dust. Unfortunately, the issue of PSA screening will probably not die out, despite this study and the recent change in the recommendation of the US Preventive Services Task Force (USPSTF), downgrading PSA testing from an “I” recommendation (evidence is insufficient to recommend for or against testing), to a “D” – not recommended. The political pressure from physicians, hospitals, and others who are at best “true believers” (they know that eventually their faith will be proven correct) to, at worst, motivated by the fear of losing a major source of income, will continue. Indeed, the “PSA velocity” was never even seen as a way of confirming the veracity of a high single PSA value (which, for the true believers, was sufficient) but a way to identify men who had a normal PSA – but maybe slowly rising from one normal value to another – as a market who could be treated. The USPSTF recommendation was in fact ready several months before it was released, as discussed by Kenny Lin, MD, on February 28, 2011 his blog Common Sense Family Doctor, PSA testing: will science finally trump politics?. Dr. Lin was, at the time, the staff member at the Agency for Health Research and Quality (AHRQ) that put together the evidence review upon which USPSTF based its recommendation, and then quit over political interference from the White House: “The USPSTF scheduled its "re-vote" on prostate cancer screening for its November 2010 meeting. As reported in the Wall Street Journal and on this blog, the Task Force was forced to cancel that meeting due to the unfortunate "scheduling conflict" with the critical midterm Congressional elections.” (Editorial note: postponing the recommendation didn’t help the President’s party in those elections!) The attraction of PSA screening and prostate cancer goes beyond that single disease; it is the cornerstone of the ostensible discipline of “Men’s Health”. This is a conceit developed by astute marketers to compete, or more correctly, profit from the cachet associated with, the long-established “Women’s Health”. After all, if Women’s Health is a good and established (and profitable) area, why should men – and particularly, those who want to make money caring for men – be left out? Women’s Health (capitalized) has its own specialty, obstetrics and gynecology, but, because this is essentially a surgical discipline, has brought in also providers in family medicine, internal medicine and some of its subspecialties (especially endocrinology, because of the issue of bone loss and osteoporosis), nurse practitioners, and others. There are Women’s Health clinics, journals, and meetings all over the place; surely Men’s Health should be just as important? The centerpiece from which Women’s Health derived is the classic “Well-Woman Exam”, an annual ritual for most adult women, so deeply enshrined in both the national culture and insurance reimbursement system that it is no danger of being overturned by a USPSTF recommendation, or probably anything else. The essential characteristic of the Well-Woman exam is the provision of preventive services because the woman is, well, Well. This is a critical concept – once someone has symptoms that are addressed by any examination (more history questions, physical exam, laboratory, imaging) or treatment, this is no longer “Well-woman”; these are problems, conceived of, addressed, and even billed separately. “Well-woman” means that the women has no symptoms and involves only screening. This screening has long been centered around the Pap smear for cervical cancer, and the internal examination (medical: bimanual = using two hands) that is so associated with the Pap that popular usage considers them together. In addition, breast health is addressed through some combination of provider exam of the breasts, teaching of self-breast exam, and referral for mammography. All of these have been re-evaluated by evidence-based studies and recommendations have changed, often for fewer tests. Breast cancer screening has been a subject of intense controversy, with USPSTF recommending that not all women over 40 receive mammography screening, reversing a position that they took 8 years earlier, and which even at that time was not based on evidence (see October 30, 2010: Breast cancer screening: conflicting evidence? what are the important questions for health?). The political response from the “breast cancer” community – and it was a political and emotional, not evidence-based scientific response, was huge, and was likely a major reason for the White House pressure on USPSTF to not release its PSA recommendation. In addition, teaching self-breast exam was no longer recommended (this is not to argue against doing self breast exam, a major way women find lumps, but rather to acknowledge the evidence that routinely teaching it does not add benefit). Pap smears themselves, the single best cancer screening tests among a group that are mostly less effective than we would hope, are no longer recommended in women under 21 by the American College of Obstetricians and Gynecologists (ACOG), and do not need to be done annually if they have been normal. Bimanual exams never had any evidence to support their routine use in asymptomatic women, because they cannot screen for any disease. Osteoporosis treatment with bisphosphonate drugs can sometimes lead to serious fractures; recommendations are now to treat only frank osteoporosis, not the less severe osteopenia, and then only for a limited time. Even calcium supplementation has been found to have risks (August 2, 2010, Calcium, Heart Attack and Osteoporosis). Does this mean that there is no valid place for Women’s Health as a concept or even a discipline? Not necessarily. Women do have risks for conditions that are different from those of men, including for a number of things that men are deeply involved in – contraception (not a risk if there are not men involved), sexual abuse, domestic violence. Asking about these issues is critical, with counseling about them necessary, even if this is not what “Well-Woman” exams usually pay for. And, to the extent that it increases the likelihood that these issues are addressed, Men’s Health may have a place. But in general, the examples above indicate the slippery slope of creating such a field, because there is a need to justify its existence. This means finding tests that can be done, expanding the use of these tests beyond those in whom they were originally found to be useful, and even implementing treatment for which there is no evidence, and which are often found to create net harm. Prevention is a good thing, but if a test or intervention has not been shown to actually prevent something, doing it is useless and costly at best, and maybe dangerous at worst. Women and men should get the screening tests that are indicated, but not those that aren’t. These include Pap smears and mammography (in the appropriate women), colon cancer screening, blood pressure screening and treatment, counseling about tobacco and alcohol, contraception and investigation of risks of violence and abuse. There are others, particularly in certain sub-populations. But we need to be cautious about the creation of new disciplines and the motivation for their creation – is it increasing health or increasing revenue? Providers, doctors and hospitals, like to do things that make money and promote the fact that they do them; cancer prevention and care is particularly emphasized (January 16, 2010: Cancer Care and Hospital Advertising). We have “Hallmark holidays” (and as a resident of Kansas City, home of Hallmark, I have to be cautious here), like Mother’s Day and Father’s Day, created and promoted to sell things, that have become very beloved by a large number of people. We don’t need “Hallmark medical care”, designed by marketers to fill a niche as an opportunity to make profit. .