humani nil a me alienum puto

random rants about news, the law, healthcare law, economics and anything I find amusing

Haunting Images

I found this article interesting as it is local in flavor and surrounding what some might think is a morbid topic.  I disagree, and can see why dissection of a cadaver would be a central experience in the education of medical student. When I was in high school, I interned at the Cuyahoga County Morgue and observed an autopsy.  There I learned that Quincy (yeah, I’m that old and way before CSI) was not really how it worked.  I became an attorney, of course.

diss-colorCWRU’s Allen Memorial is putting on an exhibition of photos from a century or more ago showing medical students with their cadavers.  Many of the exhibits and photos are from the recently published book, Dissection, Photographs of a Rite of Passage in American Medicine 1880-1930 by James Edmonson from Case Western Reserve University and John Harley Warner from Yale University.  As is discussed in the link to the photo below, during this era there was limited access to cadavers for anatomical teaching.  So, learning, for many students, required a bit of self help.  We’ll leave it at that.  The link on the photo at left has some of these photos.

I find the photos fascinating.  Here we are, seeing photos of these student in the prime of their life exhibiting their anatomical subjects, that they treat well, humorously or in poor taste, but that all recently lost of the spark of life.  And these students, too, are now long, long since passed.  From the Plain Dealer article:

dissectionLong before “Tales from the Crypt ” “The Twilight Zone” and horror author Stephen King there were medical students.  Students who at the turn of the 19th-to-the-20th century posed for photos with bodies they had dissected in their studies; who gathered in groups around flesh-peeled cadavers and skulls like hunters displaying trophies…Dissection portraiture had its heyday from 1880 to 1930…The photos were a visual representation of a rite of passage dissection to a new identity a “boundary-crossing experience that left the participant forever changed ” as Warner wrote in the book…Back then there was no legal means of obtaining bodies for dissection. Some were unclaimed bodies but many were provided by grave-robbers known as “professional resurrectionists.” … Warner described most of the photos as almost “reverential” in the treatment of the subject some bearing such phrases written on the dissection tables as “Know Thyself ” “Man s usefulness endeth not with death” and “Her loss is our gain.” But he noted that others the gag photos and macabre images almost seem to revel in the transgression — posing human remains in outlandish poses or providing such accompanying table-epigraphs as “Such the vultures love ” “Rest in pieces” and “The Lord giveth We taketh away.”

via Case Western Reserve University’s Allen Memorial Medical Library displays ‘Haunting Images’ from a century ago – Metro – cleveland.com.

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Filed under: Bioethics, Health Law, Personal Posts, , , , ,

Continuing 1Q Drops In GDP and Increasing Effects in Healthcare Sector

I recently posted on a WSJ article and Reuter’s research paper on the effect of the current recession on hospitals and the healthcare system job growth.   The AHA recently surveyed over 1,000 community hospitals (of the nearly 5,000 to which they sent surveys) seeking information on the recession’s effect on the hospital sector.   Similar to the Reuter’s paper from last month, the AHA’s survey shows significant effects on hospital total margins, operating margins, efforts to reduce costs, capital plans.

Healthcare tends to be recession resistant industry, but “The Great Recession” seems to be taking its toll.  And 1Q 2009 reports of economic contraction is worse then expected.   The Department of Commerce in a report issued this morning said that real GDP decreased at a remarkable annual rate of 6.1% Q1 2009.  In Q4 2008, real GDP decreased 6.3% and .5% in 3Q 2008.   Many economists had expected a 4.7% decline in GDP for the Q1 2009.  This is the worst two quarters in more than 60 years.  Since 1947, the economy “had never contracted by more than 4% for two consecutive quarters,” according to MarketWatch.com.  Three consecutive quarter losses has not occured since 1975.

Of note from the AHA survey summary of hospitals:

  • 90 % have taken steps to reduce costs
  • 80 % have reduced administrative expenses
  • 48 % have reduced staff
  • 20 % have reduced services in subsidized service areas
  • 58 % have had at least a moderate increase in uninsured ER visits
  • 70 % have had at lease a moderate increase in uninsured/Medicaid
  • 59 % report at least a moderate decrease in electives
  • 55 % report at least a moderate decrease in admissions
  • 65 % report at least a moderate decrease in total margin
  • 39 % report a significant decrease in total margin
  • 57 % report at least a moderate decrease in operating margin
  • 43 % expect a negative total margin 1Q 2009 (vs. 26% 1Q 2008)
  • 59 % report a at least a moderate decrease days cash on hand
  • 77 % are reducing capital spending
  • 46 % are scaling back established programs for capital spending
  • 54 % have discontinued planned (not started) capital projects
  • 65 % have seen increase in physicians seeking “financial support”
  • Of these 79% for call or other services; 71% seeking employment

via AHA : Press Release : Economic Downturn Taking Toll on Patients and Communities Hospitals Serve: New Survey Finds.

Filed under: Health Law, , , ,

The Future is Here; Just Not Evenly Distributed

Interesting presentation by Futurist Jim Carol.  He asks, what will we learn if we look back to today’s health care system from the vantage point of 2020?  Many of these concepts are not completely novel, so it reminds me of the science fiction writer William Gibson who observed that “the future is here; it’s just not evenly distributed yet.”

From Jim Carol’s presentation “It’s January 15, 2020: What Have We Learned About Healthcare in the Last Decade?”, he discusses a number of trends that he thinks will reshape health care.  A few:

  • Focus on preventive medicine reshapes healthcare delivery and finance, and by 2020 patients are treated for the conditions we know they are likely to develop, rather than principally for those that they already have.
  • Focus on “customer service” as job #2 (#1 always the efficient and effective delivery of care) reshapes healthcare delivery and rebuilds the entire philosophical underpinning of the system, so that “customer focused, friendly, fast, subject to expectation metrics makes it more consistent with other economic industries.”
  • “When Silicon Valley got involved in a big way, everything changed” launching “new products, new business models, scientic discovery tools, bio-informatics platforms that provided the foundation for diagnostic medicine, and many other incredible items.”
  • “Bio-connected devices — home health care medical monitoring, diagnosis and treatment devices — [will] provid[] … a renaissance” in the modality of care.  “A good proportion of both critical and non-critical care patients [will] receive …at home… [causing a] transition[] to a virtual community oriented caregiving strategy which has resulted in cost reductions and a refocus of critical health care spending” away from inpatient services.
  • “[T]he role of medical packaging [will] transition[] from being a passive protector of the product, to becoming an active component of the overall effectiveness of the particular medication” — prescription bottles will have internet enabled RFID tags with bio-sensors, providing specific information to patient’s provider and general information to pharmecutical clinical trials about patient’s current condition and the efficacy and interactions of the drug.
  • By 2020, “the average doctor and nurse [will need to] refresh[] their entire knowledge base every 18 months [due to the velocity of innovation, knowledge growth and change].  The result [will be] that the relationship between medical colleges and students [will] change[], from a period of short term, concentrated knowledge delivery, to one of lifelong, ongoing replenishment and rejuvenation of knowledge.”

via It’s January 15, 2020: Do you know where your healthcare system is? | WorldHealthCareBlog.org.

Filed under: Health Law, Reform, ,

Podcasts I’m Listening To – Week of 4/15 – 4/26

Show Podcast
And Justice For All We The People Stories
Senator George McGovern on Abraham Lincoln We The People Stories
Using Tiny Particles To Answer Giant Questions NPR: Science Friday Podcast
It’s All Politics April 9 2009 NPR: It’s All Politics Podcast
NYT: Science Times for 4/07/2009 Science Times
CIA Interrogation Memos, Possible U.S.-Cuba Talks Top Week’s News NewsHour with Jim Lehrer Podcast | PBS
EPA Finding Opens Door to Regulating Greenhouse Gases NewsHour with Jim Lehrer Podcast | PBS
Newly-released Memos Detail Harsh CIA Interrogation Tactics NewsHour with Jim Lehrer Podcast | PBS
Fighting America’s ‘Financial Oligarchy’ NPR: Fresh Air Podcast
Kristin Chenoweth Is ‘A Little Bit Wicked’ NPR: Fresh Air Podcast
NPR: 04-17-2009 Fresh Air NPR: Fresh Air Podcast
‘Hey I’m Dead!’ The Story Of The Very Lively Ant NPR: Hmmm…. Krulwich on Science Podcast
#354: Mistakes Were Made This American Life
#378: This I Used to Believe This American Life
The American Presidency We The People Stories
From Revolution to Evolution We The People Stories
The Future of the Republican Party We The People Stories
Legacy of 1808: Deconstructing Reconstruction We The People Stories
The NAACP Centennial We The People Stories
Better Brewing Through Synthetic Biology NPR: Science Friday Podcast
Green DIY Projects To Reduce, Reuse, Recycle NPR: Science Friday Podcast
Harnessing Nanoparticles For Targeted Cancer Treatment NPR: Science Friday Podcast
Is Missile Defense Ready For Prime Time? NPR: Science Friday Podcast
Skunked? Tomato Juice Is Not The Answer NPR: Science Friday Podcast
Shields, Brooks Mull Torture Memos, Obama’s Leadership Shields and Brooks | NewsHour with Jim Lehrer Podcast | PBS

Filed under: Personal Posts, ,

The Human Analog to a Pet or a Public Resource?

Uwe Reinhardt has a piece on the Economix blog arguing for universal coverage and public financing of children’s health insurance through age 22.  Dr. Reinhardt is a professor of economics at Princeton University and a leading health policy expert.

What’s most notable about his post is his provocative start.  He asks the question:  do we in the United States view children as the “human analogs of pets … or…, as most European and Asians, as precious national treasures.”  Kind of  a disturbing question, when you think about it.  What’s he getting at?

He believes that answering this question “informs the nation’s health policy.”

If …the human analog of their parents’ pets, then … children’s health care is primarily the parents’ financial responsibility [and]…it is just and proper that, of two households with identical incomes, the one with children will have substantially less discretionary income …than does the childless household.  [I]f …national treasures — and the nation’s economic future — then …health care of children [is] the financial responsibility of society as a whole, just as is the financing of public elementary and secondary education.

Aside from remarking about S-chip and the 9 million children that are estimated to be uninsured, he also observes that Americans “seem to impute different social values to the health care of children, depending on their socioeconomic status, even if they have insurance.”  In other words, there can be a hundred dollar or more swing in basic primary care reimbursement depending whether a child is insured through private payors or public public programs.  And this price signal has real effects – many physicians, including many in Reinhardt’s New Jersey, will simply refuse to see Medicaid patients.

He then goes on to argue that a system similar to our public school system — but with vouchers for parents who would opt out of the public system — should be established for all American children under 22:

The purchasing function under this public program, that is organizing and managing care, could be delegated to private for-profit or nonprofit insurers, as in Medicaid Managed Care. Private insurers would then compete over the quality of their disease-management programs, not through judicious risk selection…[T]he fees paid providers under the public program would be set equal to the average of fees paid by the largest two or three private insurers in the state, lest the professional work of physicians caring for poor children continue to be relatively undervalued.

I think this is interesting reading in light of the McKinsey Study that I posted on recently.  If suboptimal health care is a contributing factor to sub-standard educational attainment of differing racial groups or social/economic classes in the United States, how much does our current health care financing system contribute?  How much, if any, lost GDP opportunity are we leaving on the table due to suboptimal financing of health care for children K-12?   If, as Dr. Reinhardt argues, health care for this cohort should be a public good, what’s the real GDP return on investment to Dr. Reinhardt’s program?  To me, asking and answering these questions are critically important to advance the policy debate.

via Seriously, What Is a Child? – Economix Blog – NYTimes.com.

Filed under: Bioethics, Health Law, Reform, , , ,

Birds or Pigs; The Swines Have It?

We’ve had a lot of stories the past several days about the swine flu outbreak in Mexico and smaller groupings of confirmed cases in New York, California and elsewhere in the United States.   There has been years of discussion on the H5N1, so called avian flu, pandemic risks.  We all remember the impact of SARS.  And we’ve been rocked, recently, by what some have tagged a ‘depression’ but all of noted as the largest economic downturn since The Great Depression.  The losses associated with this ‘Great Recession’ are still playing out.

But I was wondering — what if the Swine Flu became a pandemic at this time?  All indication (including the CDC site) indicate that aside from some serious implications for Mexico City’s public health, the cases in the United States have been mild, with no hospitalizations.  The 1918 flu pandemic that took 20m lives world-wide, however, is the standard modern example of potential personal and economic costs of a flu pandemic.  Not to minimize the terrible pain and suffering that such a pandemic would cause by putting an economic slant on it– but I was wondering what might be the economic impact to our already tottering United States economy if a pandemic struck.

So I took a look at a study the CDC had commissioned in 1999.  It showed the potential U.S. economic impact of a pandemic.   The CDC used this as a way to assist the public policy discussion in light of strategies regarding flu immunization — i.e., which immunization policy could provide the best net value in the case of flu pandemics of differing severity.   It’s beyond this post (or its author) to analyze the article and it’s conclusions.  But I thought the numbers were notable and summarize the potential economic exposure (without vaccination).  And, of course, this looks at U.S. exposure only.  A pandemic would have a far reach.  Look how quickly in this age of easy travel the virus spread from Mexico to the United States and even potentially exposed the President of the United States during his trip.  From the CDC’s study:

Without large-scale immunization, the estimates of the total economic impact in the United States of an influenza pandemic ranged from $71.3 billion (5th percentile = $35.4 billion; 95th percentile = $107.0 billion) (gross attack rate of 15%) to $166.5 billion (5th percentile = $82.6 billion; 95th percentile = $249.6 billion) (gross attack rate of 35%) (Table 6). At any given attack rate, loss of life accounted for approximately 83% of all economic losses. Outpatients, persons ill but not seeking medical care, and inpatients accounted for approximately 8%, 6%, and 3%, respectively, of all economic losses (Table 6) (Appendix II).

* * * *

If it cost $21 to vaccinate a person and the effective coverage were 40%, net savings to society would result from vaccinating all age and risk groups (Figure 2). However, vaccinating certain age and risk groups rather than others would produce higher net returns. For example, vaccinating patients ages 20 to 64 years of age not at high risk would produce higher net returns than vaccinating patients ages 65 years of age and older who are at high risk (Figure 2). At a cost of $62 per vaccinee and gross attack rates of less than 25%, vaccinating populations at high risk would still generate positive returns (Figure 2). However, vaccinating populations not at high risk would result in a net loss (Figure 2).

via The Economic Impact of Pandemic Influenza in the United States: Priorities for Intervention.

There’s also an interesting Congressional Budget Office (CBO) assessment (and see generally the goverment web page)  of possible economic effects of an avian flu pandemic.  That study concludes that a pandemic involving a highly virulent flu strain (such as the one that caused the pandemic in 1918) could produce an impact worldwide similar in depth and duration to an average postwar recession in the United States — but citing studies ranging from a .5% to 6% decrease in GDP.  Query, of course, what impact if such a pandemic hit during an ongoing recession.

Filed under: Comparative Effectiveness Rearch, Health Law, Personal Posts, Pharmacy, Risk Management, , , ,

I.M.F. Puts Bank Losses From Crisis at $4.1 Trillion – DealBook Blog – NYTimes.com

A recent IMF report increases the total write-downs that are anticipated wordwide as a result of the current financial crisis.  These numbers are just simply staggering:

[T]he International Monetary Fund estimates that banks and other financial institutions face aggregate losses of $4.1 trillion in the value of their holdings as a result of the crisis…[F]inancial institutions would have to write down an estimated $2.7 trillion in loans and securities originating in the United States from 2007 to 2010…Banks are expected to shoulder about two-thirds of the write-downs…though other institutions, like pension funds and insurance companies, also face heavy losses…Banks have raised about $900 billion in fresh capital since the crisis began…, but that is far outweighed by $2.8 trillion in credit-related losses. The fund estimates that the banks have already taken about one-third, or $1 trillion, of those write-downs….United States…banks reported $510 billion in write-downs by the end of 2008 and face an additional $550 billion in 2009 and 2010. In the euro zone, banks reported just $154 billion in write-downs by the end of last year and still face $750 billion. British banks are in somewhat better shape: having written down $110 billion, they face $200 billion more, the fund said.

via I.M.F. Puts Bank Losses From Crisis at $4.1 Trillion – DealBook Blog – NYTimes.com.

Filed under: Personal Posts, , ,

How Might The Education and Healthcare Sectors Be (Economically) Alike?

Thomas Friedman had an interesting op ed today.  He cited a recent McKinsey Study entitled The Economic Impact of the Achievement Gap in America’s Schools.   I read his op ed, but thought to take a look at the summary of the McKinsey Study.  It points out the potential for huge future improvement opportunity in the educational sector, if only that current opportunity may have been lost.  It also discusses an important similarity between the education sector and the health care sector that is worth remark.

Before briefly discussing the McKinsey study, it uses a report, made a generation ago, “A Nation at Risk”, as a springboard.  I just revisited that report this evening.  I recall reading it in an undergraduate education (elective) class a long time ago.  That 1983 report (by the National Commission on Excellence in Education presented to Secretary of Education) began:

Our Nation is at risk. Our once unchallenged preeminence in commerce, industry, science, and technological innovation is being overtaken by competitors throughout the world… History is not kind to idlers. The time is long past when American’s destiny was assured simply by an abundance of natural resources and inexhaustible human enthusiasm…We compete with them for international standing and markets, not only with products but also with the ideas of our laboratories and neighborhood workshops. America’s position in the world may once have been reasonably secure with only a few exceptionally well-trained men and women. It is no longer.

educationThis McKinsey study asks the question: if we had effectively acted in 1983 and closed the international, racial and class/economic gaps in US k-12 educuation, where would we be today?  They stay away from the ‘moral’ and ‘equity’ component of fulfillment of some of the aspects of that old report’s recommendations and keep it at the level of national economic productivity.  The answer is that if we had done better, we’d be, as a society, a lot richer.

We’re now in the midst of the greatest economic downturn in generations.  Economists thinks that the current ‘Great Recession’ has depressed economic output of the United States by somewhere between $1T to $2T.  If the McKinsey study analysis is to be believed, however, we are experiencing staggering lost opportunities in gross national product performance that surpass even those numbers.  The study puts it this way:

[T]he international achievement gap is imposing on the US economy an invisible yet recurring economic loss [of $1.2T to $2.3T per year] that is greater than the output shortfall in what has been called the worst economic crisis since the Great Depression. In addition, the racial [gap of between $310B to $525B per year], income [gap of $400B to $670B per year], and system achievement gap[] [of $425B to $700B] all impose annual output shortfalls that are greater than what the nation experienced in the recession of 1981–82, the deepest downturn in the postwar period until now. In other words, the educational achievement gaps in the United States have created the equivalent of a permanent, deep recession in terms of the gap between actual and potential output in the economy.

Fundamentally,  our society is experiencing lost opportunity and it affects all of us in very real objective ways.  But lost opportunity is opportunity that can be regained.  So, where is this opportunity?  The healthcare sector and the education sector share an important and remarkable trait according to the McKinsey study authors.  As the McKinsey article points out:

The most striking, poorly understood, and ultimately hopeful fact about the educational achievement gaps in the United States involves the huge differences in performance found between school systems, especially between systems serving similar students. This situation is analogous to that found across American health care, where, as researchers like John Wennberg have shown, wide regional variations in costs and utilization of procedures and services exist that bear no relation to quality or health outcomes. In each case, these differences prove there are substantial opportunities to improve…

While at the racial and economic level there are sizable differences in attainment — controlling for these demographic differences one still finds amazing variations in student achievement.   The study authors point out that research shows that these variations “exist at every level in American education: among states, among districts within states, among schools within districts, and among classrooms within schools.”   “Intuition” and “research” suggest that differences in “public policies, systemwide strategies, school site leadership, teaching practice, and perhaps other systemic investments can fundamentally influence student achievement.”

spending3The authors also point out that there seem to be gross inefficiencies in the educational sector.   While they do not extend, by analogy, to the health care sector, I’ve seen other studies that could.  Despite the United State’s very significant per capita education spending, we might have one of the least cost-effective educational systems in the world. The study authors report that by “one measure we get 60 percent less for our education dollars in terms of average test-score results than do other wealthy nations.”  In other words, as the chart from the report shows, we spend more per student to obtain one point on the Program for International Student Assessment (PISA) Math test (2003 data) than any other nation.  We pay a lot to perform far less well than our international peers.

While the authors do not make very specific recommendations regarding reform, ultimately, their main forward looking conclusion can be summed up by the Lord Kelvin observation:  ‘if you cannot measure it, you cannot improve it.’  The corollary — if you can measure it, and use “relentless efforts to benchmark and implement what works[,]” performance can be significantly improved.

This is an interesting and sober read and I recommend it.

Filed under: Comparative Effectiveness Rearch, Health Law, Personal Posts, , , ,

The Public and the Health Care Delivery System

The Kaiser Family Foundation, NPR and the Harvard School of Public Health recently conducted a poll of public attitudes concerning EHR, coordination of care, patient and doctor interaction around effectiveness and cost, the cost of care, the role of government and insurers in cost and comparative effectiveness, the uninsured and cost.  I found a few of the findings from the survey of note.

  • A larger portion of respondents (34%) thought that EHR’s would actually increase costs of healthcare in America than decrease (22%) it.  Even more (39%) thought it would increase their own family’s healthcare costs!
  • There is significant concern about unauthorized access (76%) to online medical records.
  • A significant minority (40%) of Americans report at least minor problems with coordinating care between their different doctors, while half say this is not a problem at all. A smaller minority (17%) say they experience “major problems” coordinating their health care services.   Interesting, those Americans who reported having personally experienced at least three ‘coordination of care’ issues are much more likely (63%) to see overtreatment in the system as a whole compared to other Americans (48%).
  • About half (49%) think that overutilization is a major problem.  Of course, only a minority (16%) say that they have received unnecessary care and a bit more than half (56%) think that insurance companies should have to cover expensive treatments even if they have not been proven more effective than other, less expensive options.
  • A significant majority of Americans  (72%) believe that there is not always clear scientific evidence about which treatment is likely to work best for any one patient.  But only a small minority (9%) say that they have received an expensive medical test or treatment in which a less expensive alternative would have been just as good.
  • A significant majority of Americans (65%) say their doctor’s charges are reasonable and (63%) believe that their doctor is working to keep the cost of their health care down.
  • There is a significant disconnect between the actual cost of insurance and what uninsured Americans are willing to spend for insurance.  Majorities report being willing to pay $25, $50 or even $100 per month for coverage, but only a minority (29%) would pay $200 per month, and only a very small minority (6%) say they would pay $400.  (Nationwide, annual premiums averaged $2,613 for single coverage and $5,799 for family plans in the 2006-2007 period).

The WSJ Health Blog commented on this survey: while patient seem to recognize that there is waste in the system, it wasn’t their physician.  She’s perfect.

Filed under: Comparative Effectiveness Rearch, Health Law, Reform, , ,

Republicans And Universal Health Care (Only Nixon Could Go to China)

Regina Herzlinger (the McPherson Chair at Harvard Business School and author of Who Killed Health Care? (McGraw Hill, 2007); a health care adviser to John McCain’s presidential campaign) writes an interesting op-ed in the Atlantic.  She argues that the Republicans need to seize the moment, realize that the “time for universal health insurance coverage has come” and that they should go to China, figuratively speaking.  “Republicans should…seize the lesson of Nixon’s trip to China”, where in one swoop Nixon brought the middle Kingdom out of isolation and removed the issue from his political adversaries.  [As Spock says in Star Trek VI, there’s an old Vulcan proverb that ‘only Nixon could go to China’ — perhaps only the Republicans can get sustainable health care reform passed?].

Ms. Herzlinger argues that there is a “a massive constituency behind [a potential Republican] policy” and her fellow republicans can do a “better version of universal coverage.”  She highlights challenges with what appears to be the current Democratic plan to rely “on universal coverage through a government-controlled system like Medicare”: (i) distrust government’s ability to apply fiscal controls needed so that any plan would not bankrupt us as Medicare is appearing to do; (ii) concern that the government will control costs by rationing health care to the sick (citing the UK experience with cancer rate survival due to UK’s pathetic approval of new cancer drugs and therapies); (iii) government as a monopolistic buyer of health care could negatively affect the supply of doctors; and (vi) government-controlled system would likely impair the medically and economically important private investment — particularly in the emerging genomic sector.

The Republicans, she argues, should instead offer a “consumer-controlled universal coverage system, like that in Switzerland in which the people, not the government, control how much they spend on health.”  The Swiss choose from 85 private health insurers.  [I believe that the Swiss government causes a degree of plan standardization so that consumers can compare “apples to apples.”]  In Switzerland, the poor shop for health insurance like everyone else, using funds transferred to them by the government.  Rather than the “degraded” Medicaid program, the Swiss poor get the same insurance options that everyone else get.  The Swiss taxing authority, according to Ms. Herzlinger, enforce the mandatory system and achieve 99% enrollment.

This consumer-driven, universal coverage system provides excellent health care for the sick, tops the world in consumer satisfaction, and costs 40 percent less, as a percentage of GDP, than the system in the US. The Swiss could spend even less by choosing cheaper, high deductible health insurance policies, but they have opted against doing so. Swiss consumers reward insurers that offer the best value for the money. These competitive pressures cause Swiss insurers to spend only about 5 percent on general and administrative expenses, as compared to 12-15 percent in the US. And unlike Medicare, the private Swiss firms must function without incurring massive unfunded liabilities. Competition has also pushed Swiss providers to be more efficient than those in the US. Yet they remain well-compensated.

She cautions that the Swiss system is not perfect, we can learn from it.  It maintains some of the same problems we have with fragmented care and poor integration of payments between vertical provider groups for episodes of care.

She concludes by observing that movement to this model will have real economic impacts:

Republicans could enact Swiss-style universal coverage by enabling employees to cash out of their employer-sponsored health insurance. (Although many view employer-sponsored health insurance as a” free” benefit, it is money that would otherwise be paid as income.) The substantial sums involved would command attention and gratitude: a 2006 cash out would have yielded $12,000 — the average cost of employer-sponsored health insurance — thus raising the income of joint filers who earn less than $73,000 (90 percent of all filers) by at least 16 percent. Employees could remain in with an employer’s plan or use this new income to buy their own health insurance.

via Why Republicans Should Back Universal Health Care – The Atlantic Business Channel.

Filed under: Health Law, Reform, , ,

Factors Influencing Physicians Prescribing NAIDs

In his Healthcare Economist blog, Jason Shafrin, Ph.D. (just recieved – congrats) reported on a recent study in The American Journal of Managed Care concerning the prescribing habits of Nonsteroidal Anti-Inflammatory Drug (NAIDs) among physicians.  The study, entitled Pharmaceutical Company Influence on Nonsteroidal Anti-Inflammatory Drug Prescribing Behaviors, describes, through interviews with academic medical center physicians from a variety of specialities, their prescribing habits in order to elicit the general themes that influence their behavior.  As Jason summarizes from the article, they are mostly influenced by the following:

  1. Direct Marketing by pharma detailers.
  2. Patient requests for medication, often driven by direct-to-consumer pharmaceutical advertising.
  3. Habits formed during medical school. Often, these habits are influenced by drug rep visits while the physician was in medical school.
  4. Journals, electronic peer-reviewed literature, and professional meetings.
  5. Local physician expert opinion and practice guidelines.
  6. The physician’s own experience prescribing drugs to patients.

The purpose of the study was to “describe the taxonomy of methods used by pharmaceutical companies to influence physicians’ nonsteroidal anti-inflammatory drug (NSAID) prescribing behaviors and to elicit physicians’ perceptions of and counterbalances to these influences” since there was a recognized poor adherence to prescribing guidelines for NSAIDs.  The study recognized that physicians describe detailing and direct contact with pharmaceutical representatives, requests from patients inspired by direct-to-consumer advertisements, and marketing during medical school and residency training as primary influences.  The study also reports that physicians described practice guidelines, peer-reviewed evidence, and opinions of local physician experts as important counterweights to pharmaceutical company influence.

The study concludes that the “social and communicative strategies used by pharmaceutical companies can be adapted to improve physicians’ adoption of guidelines for safer NSAID prescribing. Communicative interactions between local experts and other physicians who prescribe NSAIDs may be the critical target for future interventions to promote safer NSAID prescribing.”

Aanand D. Naik, MD and Aaron L. Woofter, MD et al,  (2009) “Pharmaceutical Company Influence on Nonsteroidal Anti-Inflammatory Drug Prescribing Behaviors,” Am J Manag Care. 2009 (published online April 1, 2009 and found online April 18, 2009 at http://www.ajmc.com/web-exclusives/managed-care/AJMC_09Apr_Naik_Exclusiv_e9toe15?utm_source=Listrak&utm_medium=Email&utm_term=%2fweb-exclusives%2fmanaged-care%2fAJMC_09Apr_Naik_Exclusiv_e9toe15&utm_content=jshafrin%40ucsd.edu&utm_campaign=AJMC+e-Table+of+Contents+(April+Web+Exclusive)).

via [AJMC] – American Journal of Managed Care.

Filed under: AKS, Conflicts of Interest, Drug Policy, Health Law, Pharmacy, , ,

HHS issues guidance on safeguarding PHI

On Friday, April 18, 2009, the Department of Health and Human Services released its guidance on protecting personally identifiable healthcare information by encrypting or destroying it so that it is rendered “unusable, unreadable or indecipherable to unauthorized individuals.”  (See http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/hitechrfi.pdf).

Because the breach notification requirements of the HITECH Act apply only to breaches of unsecured PHI, the Department’s guidance provides the means by which covered entities and their business associates are to determine whether a breach has occurred to which the notification obligations under the Act and its implementing regulations apply.   Recall that under the HITECH Act, if there is a “breach” of  “unsecured PHR identifiable information” as personal health record (PHR) identifiable health information that is not protected through the use of a technology or methodology specified in the Secretary’s guidance (this document), and the “breach” is not qualified as provided in the HITECH Act, then certain disclosures by the covered entity are required.  These would include direct certified mail disclosure to individuals, “in cases in which there is insufficient or out-of-date contact information, substitute notice, including, in the case of 10 or more individuals for which there is insufficient contact information, conspicuous posting (for a period determined by the Secretary) on the home page of the Web site of the covered entity” and in cases of 500 or more records notice to prominent media outlets within the State or jurisdiction and immediately to the Department.   Notice by covered entities to HHS of all breaches is also required on an annual basis.  The Secretary will also post to its web-site notice concerning all disclosed breaches of 500 patient records or more.

[W]e have identified two methods for rendering PHI unusable, unreadable, or indecipherable to unauthorized individuals: encryption and destruction *** Protected health information (PHI) is rendered unusable, unreadable, or indecipherable to unauthorized individuals only if one or more of the following applies:

a) Electronic PHI has been encrypted as specified in the HIPAA Security Rule by “the use of an algorithmic process to transform data into a form in which there is a low probability of assigning meaning without use of a confidential process or key”15 and such confidential process or key that might enable decryption has not been breached. Encryption processes identified below have been tested by the National Institute of Standards and Technology (NIST) and judged to meet this standard.

i) Valid encryption processes for data at rest are consistent with NIST Special Publication 800-111, Guide to Storage Encryption Technologies for End User Devices.17

ii) Valid encryption processes for data in motion are those that comply with the requirements of Federal Information Processing Standards (FIPS) 140-2. These include, as appropriate, standards described in NIST Special Publications 800-52, Guidelines for the Selection and Use of Transport Layer Security (TLS) Implementations; 800-77, Guide to IPsec VPNs; or 800-113, Guide to SSL VPNs, and may include others which are FIPS 140-2 validated.

b) The media on which the PHI is stored or recorded has been destroyed in one of the following ways:

i) Paper, film, or other hard copy media have been shredded or destroyed such that the PHI cannot be read or otherwise cannot be reconstructed.

ii) Electronic media have been cleared, purged, or destroyed consistent with NIST Special Publication 800-88, Guidelines for Media Sanitization,19 such that the PHI cannot be retrieved.

The Department indicates that its list is an exhaustive list, but it opens discussion of other methods to make PHI unusuable, unreadable, or indecipherable.  In the development of this guidance, the Department reported that it had considered whether PHI in limited data set form should be treated as unusable, unreadable, or indecipherable to unauthorized individuals for purposes of breach notification.  It does not, but suggests that in the future, based upon additional comments and analysis, further restrictions on Limited Data Sets (e.g., removal of some of the digits of ZIP code) might effectively make re-identification such a remote possibility that the more limited data set would be unusable, unreadable, or indecipherable.  The Department also ask for comment on use of fingerprint protected Universal Serial Bus (USB) drives, for example, or whether it should, in providing future guidance on this topic, identify specific “off-the-shelf” products that may “meet the encryption standards identified in this guidance.”

In advance of its guidance to be issued on its interim final regulations on breach notifications, it also asks for comments.  The request for comments seems to indicate that the Department is concerned about need for covered entities to send multiple notices due to inconsistency between federal and state legal requirements.  They also are seeking examples of situations that covered entities think that the exceptions under the HITECH act will actually apply (perhaps to agree, disagree or to use in their own illustrative examples).

1.  Based on experience in complying with state breach notification laws, are there any potential areas of conflict or other issues the Department should consider in promulgating the federal breach notification requirements?
2.  Given current obligations under state breach notification laws, do covered entities or business associates anticipate having to send multiple notices to an individual upon discovery of a single breach? Are there circumstances in which the required federal notice would not also satisfy any notice obligations under the state law?
3.  Considering the methodologies discussed in the guidance, are there any circumstances in which a covered entity or business associate would still be required to notify individuals under state laws of a breach of information that has been rendered secured based on federal requirements?
4. The Act’s definition of “breach” provides for a variety of exceptions. To what particular types of circumstances do entities anticipate these exceptions applying?

Filed under: Health Law, HIPAA, , , ,

Calvin 2.0 – The Future

The Future

The Future

Filed under: Personal Posts

Recession Now Hits Jobs in Health Care

In the April 12, 2009 WSJ, they report on healthcare sector softening as the recession lingers.   The article mentions cuts at Mayo, Akron General and others.  Also quotes Paul Levy from Beth Israel Deaconness in Boston (author of Running a Hospital blog earlier posted about concerning their transparent efforts at saving costs):

More than 16 million people — one in eight workers on U.S. payrolls — work in health care today, up from just 1% of the work force 50 years ago…Employment in health care and social assistance — which includes hospitals, doctors offices, nursing homes and social services such as day care — has grown by half a million jobs since the recession began in December 2007, while the rest of the economy has shed 5.1 million jobs…But the pace of job growth in health services has slowed sharply this year. The sector added an average of 17,000 jobs per month in the first three months of the year, less than half last year’s pace…Since1958, there have been nine recessions, but employment in health services has declined only a handful of times…The only significant losses to date occurred in mid-1984, as the industry shed 41,000 jobs…Since then, no month has seen a drop of more than 4,000 jobs in health care, and there have been no back-to-back declines…The decline, while unusual, is still likely to be a temporary break in the industry pattern. Growth in health-care spending, and thus employment in the sector, is likely to rebound when the recession ends, a function of the enormous advances in medical technology and Americans’ strong appetite for health care… “It’s a long-term shift reflecting changes in technology and what consumers want,” says Robert Fogel, a Nobel laureate and professor at the University of Chicago’s Booth School of Business. “Health care is the growth industry of the 21st century.”

via Recession Now Hits Jobs in Health Care – WSJ.com.

Compare to an earlier analysis of the state of US Hospitals and the Current Recession.  Hospitals may be recession resistant; but are by no means recession proof:

“Observed impacts that appear related to the recession:

• Hospital non-operating and total margins have decreased dramatically, especially in the third quarter of 2008. Total margins are at historically unprecedented lows.

• Approximately 50% of hospitals are operating in the red.

• Hospital days-cash-on-hand has deceased significantly, following a pre-recession trend.

• Restricted investment assets have shrunk substantially for major teaching hospitals. These are non-realized losses that are not reflected in total margins declines.

• Hospital reimbursement rate increases appear to be shrinking — with possible negative impacts on net patient revenue in 2009.

• Total inpatient admission volumes may be falling below expectation.

Filed under: Health Law, Reform, , , ,

P.W. Singer TED Presentation: Wired For War

I really love the talks on TED.  See my earlier post.  I heard one tonight that I wanted to log.  Peter Warren Singer is the director of the 21st Century Defense Initiative at the Brookings Institution.  His TED talk discusses his current book, Wired for War, and the emerging use of robotics to replace humans on and above the battlefield.   He’s been out on the circuit promoting his book — I heard him on NPR’s Fresh Air a few months back.

What’s fascinating about all this is how quickly some of these technologies are now emerging.  The robotic pack mule, the drones, etc. are amazing.  But even more interesting is the psychological and practical effect these technologies might have.  I think we are entering a world of profound unintended consequences.  No, not Terminator — but maybe disturbing.  Take a look.

Filed under: Personal Posts, , , , ,

Friedman Talks about Externalities – No Drill Baby Drill

I love it when someone talks about externalities.  I’m twisted that way.  It gets me going.

As long as I’ve been reading his column, Friedman has continually hit the drum beat for us to recognize the true costs in our use of energy.   The price we pay for our carbon based energy is not fully loaded.  In his article today, he gives us some examples of how we miss these externalities, while he talks about the energy and conservation policies of one of our neighbors to the south.

[I]f a chemical factory sells tons of fertilizer but pollutes a river — or a farm sells bananas but destroys a carbon-absorbing and species-preserving forest — this is not honest growth. You have to pay for using nature. It is called “payment for environmental services” — nobody gets to treat climate, water, coral, fish and forests as free anymore…Right now, most countries fail to account for the “externalities” of various economic activities. So when a factory, farmer or power plant pollutes the air or the river, destroys a wetland, depletes a fish stock or silts a river — making the water no longer usable — that cost is never added to your electric bill or to the price of your shoes.

In fact, there are hidden costs in almost every market.   Many items in a our markets have significant positive and negative externalities.  Friedman provides examples of negative externalities above: the classic example of pollution needing to be recognized in the ‘true’ cost of a product.  But there are also positive externalities.  Accessible public eduction, for example, is the most profound one that has reshaped the United States and our civilization.  If not subsidized through taxes, far fewer would receive education to the detriment of society as a whole.  Tax payers paid more today for a benefit that paid dividends a decade or a generation later.

The bottom line of all this is that if you do not recognize the real cost or benefit of goods and services in a market you will over utilize certain goods and under utilize others.  So, what are we to do if energy markets contain significant externalities?  Well, you and I can’t do much.  We, individually, are  incapable of recognizing these true costs since they are spread out to everyone and energy costs are bundled into just about every downstream derivative product or service we utilize.  Oh sure, a many of us can take actions such as “recycling” and using canvass bags and, maybe, use those lousy fluorescent bulbs to a point.   Stuff that makes us feel good — and it might help to a point.   But externalities have to be addressed systemically — because they are a systemic market problems.

Please do not misunderstand me.  No one should be taking the position that individuals or energy corporations are acting irresponsibly.  Quite the contrary.  They are acting rationally.  It’s the market that’s out of whack.  The objective of a corporation is to maximize return to shareholders within legal constraints.  They have no requirement to identify the true cost of an item to others unless there is some legal contraint that they do so, be it tort law or some regulatory regime.   In fact, if they can arbitrage by exploiting unrecognized externalities, then not only will they, but they must due to their legal directive to shareholders.  And if they do not and their competitors do — they’ll risk being driven from the market.  And you and me, while individuals are as diverse as can be, number in the billions.  In the aggregate and in the longer term, we react en mass to price signals that a market provides more than any other factor.

So, what’s to do?  Well, identifying significant distorting externalities is a core responsibility of government. Friedman gives the example of Costa Rica in his article.

More than any nation I’ve ever visited, Costa Rica is insisting that economic growth and environmentalism work together. It has created a holistic strategy to think about growth, one that demands that everything gets counted.  So it did something no country has ever done: It put energy, environment, mines and water all under one minister… [W]hen Costa Rica put one minister in charge of energy and environment, “it created a very different way of thinking about how to solve problems,”…‘Look, [the minister was able to say,] if you want cheap energy, the cheapest energy in the long-run is renewable energy.  So let’s not think just about the next six months; let’s think out 25 years.’”… [A]nd today it gets more than 95 percent of its energy from these renewables.

So does this mean taxes?  Sure.  Be it direct or a cap and trade system, it’s about taxes.  See Friedman’s article earlier in the week.  We tax a lot of things due to their externalities.  We already tax gas in part because of this in order to maintain roadway infrastructure — which use of gas impacts.  The important point that, if done correctly, and that’s a big ‘if’, the net cost to everyone is far less over time than the cheaper fuel today.

To pay for these environmental services, in 1997 Costa Rica imposed a tax on carbon emissions — 3.5 percent of the market value of fossil fuels … If government policies don’t recognize those services and pay the people who sustain nature’s ability to provide them, things go haywire. We end up impoverishing both nature and people. Worse, we start racking up a bill in the form of climate-changing greenhouse gases, petro-dictatorships and bio-diversity loss that gets charged on our kids’ Visa cards to be paid by them later. Well, later is over. Later is when it will be too late.

I think we’ve finally moved away from the question of whether there are significant externalities in the energy products sector.   You don’t really have to look to ‘global warming’ for this.  You need only realize that carbon based fuels are a finite supply and a critical resource.  The demand/supply curve very possibly will not price the commodity in gradual manner to encourage the infrastructure development to move away from it.  So it’s a pay me now or pay me a lot more later question if sudden price distortions hit the market and then stick around, unlike the 1970s and last year.   So, in any event, we’re finally onto the policy questions:  (a) how big are these unloaded costs and (b) what mechanism or mechanisms do you use to incorporate the true price into these products.

The first is a function of policy choices relying upon terribly incomplete data.  How big is the global warming problem?  What is the probabilities related to loss of GNP in the future due to global warming?  What’s the potential costs of politically fragile regions holding so much of the word’s supply of carbon based fuels?  Carbon based fuels are finite — what is the realistic time frame that they will remain economically cost effective?  Will pricing really gradually rise to encourage alternative development or is the infrastructure costs so huge that we have to encourage significant R&D and infrastructure alternatives earlier?  What effects would major disruption have on supply, the cost of oil and related GNP growth stability?  These are really meaty questions without hard answers.   But we have to make policy judgements on these types of unknows all the time.   Insurers do this every day — they figure out potential costs and probablities of poutcomes and attribute premiums accordingly.  (AIG’s credit swaps, perhaps, excluded. )

And practically, what mechanism is politically possible to pass through Congress?  Can we articulate why we are choosing those mechanisms and the underlying issues.  These are really difficult policy decisions.  And vested interests (and you and me who might not understand why higher prices today mean for much lower overall cost tomorrow) have the ability to block rational policy making.  Still, like Friedman, I remain hopeful.

via Op-Ed Columnist – (No) Drill, Baby, Drill – NYTimes.com.

Filed under: Personal Posts, , , , ,

PartnersHealthCare Announces Industry Relationship Policy

The WSJ Health Blog in its April 10, 2009 posting reported that Parterns Healthcare, which includes Harvard-affiliated Mass General, had issued a report recommending tighter restrictions on industry relationships with its physicians.

The news release by Partners listed key recommendations from its report:

Prohibition of all gifts, including meals and funding for meals, provided directly to staff by industry for their personal use, on a Partners site or off site. This ban also applies to Partners institutions accepting industry gifts for this purpose.

Development of mechanisms to have free drug samples distributed only through the hospital pharmacy or some other centralized system, and not provided directly to or distributed by physicians.

Requiring that industry representatives have written invitations defining the purpose and terms of visits before having access to Partners sites and staff.

Establishment of a process to identify and manage significant financial interests held by physicians in companies that make products they prescribe or use in their practices.

Acceptance of industry funding for educational programs and fellowships only if provided through a centrally pooled institutional President’s Fund at each hospital or approved by a newly-created, Partners-wide Educational Review Board.

Establishment of a robust, tiered approach to evaluate research-related conflicts of interest, including continued prohibition of certain high-risk circumstances.

Adoption of a stricter policy holding certain officials to a higher standard because of their influential positions within the organization.

Strengthened oversight of permitted outside activities, including a ban on faculty participation in industry speakers bureaus, an express prohibition on faculty being listed as authors on papers ghostwritten by others, and a more rigorous internal review process for certain outside activities.

Development of an enhanced infrastructure, including creation of a new Conflict of Interest Review Committee, responsible for education, oversight, and enforcement of Partners policies and practices in regard to industry interactions.

The system plans to adopt revised policies and procedures by October 1, 2009 and acknowledges that a significant training and education program will be necessary during the roll-out of these changes.  The 30 page report details the commissions charge, its process, its internal review, external factors and recommendations. The press release link is below.

CommissionPressRelease_PartnersHealthCare2009.pdf (application/pdf Object).

Filed under: Conflicts of Interest, Drug Policy, Fraud and Abuse, Health Law, Reform, , , ,

Researcher Faked Data in Sleep Apnea Study – Health Blog – WSJ

The WSJ Health Blog reports another individual fabricating research study data.  Not much about industry ties, except that he later went on to work in industry.

“Robert Fogel, a former assistant professor at Harvard Medical School, fabricated and falsified data in a study of sleep apnea in severely obese patients, the Office of Research Integrity at HHS said…Fogel, who worked at Brigham and Women’s Hospital at the time but later moved on to work at Merck, told a former supervisor in 2006 that he had falsified the data, the Scientist reports.”

via Researcher Faked Data in Sleep Apnea Study – Health Blog – WSJ.

Filed under: Conflicts of Interest, Health Law, , , ,

Op-Ed Columnist – The End of Philosophy – NYTimes.com

In his op-ed peice in the April 6, 2009 NYT, David Brooks takes on a discussion of moral philosophy.   He believes that recent movement in theory behind why we have it has moved from the older, Socratic, notion of rationally based morality to one based upon the evolutionary development of human emotion and humans as a social, collaborative creature.  In it he writes:

The question then becomes: What shapes moral emotions in the first place? The answer has long been evolution, but in recent years there’s an increasing appreciation that evolution isn’t just about competition. It’s also about cooperation within groups. Like bees, humans have long lived or died based on their ability to divide labor, help each other and stand together in the face of common threats. Many of our moral emotions and intuitions reflect that history. We don’t just care about our individual rights, or even the rights of other individuals. We also care about loyalty, respect, traditions, religions. We are all the descendents of successful cooperators. *** The rise and now dominance of this emotional approach to morality is an epochal change. It challenges all sorts of traditions. It challenges the bookish way philosophy is conceived by most people. It challenges the Talmudic tradition, with its hyper-rational scrutiny of texts. It challenges the new atheists, who see themselves involved in a war of reason against faith and who have an unwarranted faith in the power of pure reason and in the purity of their own reasoning.

I’m not so sure about the line about the “new atheists”.  It seems that the biological and evolutionary research that is shedding so much light on how we’ve developed our morality is coming from thoughtful scientific method, rather than an introspective rational philosopher waxing over long dead texts.

But, in any event, for some reason, this also reminded me of a passage from one of my recent favorite authors, Terry Pratchett.  From Hogfather:

Susan: “All right, I’m not stupid. You’re saying humans need … fantasies to make life bearable.”
Death: “No. Humans need fantasy to be human. To be the place where the falling angel meets the rising ape.
Susan: “But Tooth fairies? Hogfathers?”
Death: “Yes. As practice. You have to start out learning to believe the little lies.”
Susan: “So we can believe the big ones?”
Death: “Yes. Justice. Mercy. Duty. That sort of thing.”
Susan: “They’re not the same at all!”
Death: “Take the universe and grind it down to the finest powder and sieve it through with the finest sieve and then show me one atom of justice, one molecule of mercy. And yet you act as if there were some sort of rightness in the universe by which it may be judged.”
Susan: “Yes. But people have got to believe that or what’s the point—”
Death: “My point exactly.”

Filed under: Personal Posts

Hospital Gets Subpoena Tied to Doctor’s Studies – WSJ.com

The WSJ and its WSJ Health Blog report that Baystate Medical Center has been subpeoned for records related to Scott S. Reuben, a Massachusetts doctor accused of faking data used in at least 21 anesthesiology studies.  The accused physician, was also on the faculty of Tufts University medical school.

Some of his research was funded by Pfizer Inc., Wyeth and Merck & Co., Wyeth said it provided $10,000 in grant money to Dr. Reuben from 2001 to 2003.  According to the WSJ Health Blog, Pfizer had funded some of Reuben’s research and had also paid him to speak on behalf of its medicines.

via Hospital Gets Subpoena Tied to Doctor’s Studies – WSJ.com.

Filed under: Compliance Programs, Conflicts of Interest, Health Law, ,

Johns Hopkins Bans Free Drug Samples, Gifts from Industry – Health Blog – WSJ

As reported in the April 8, 2009 WSJ Health Blog, John Hopkins is the latest to adopt a restrictive policy on ‘on interaction with industry.’  the new policy “bans free drug samples and says doctors can’t participate in consulting gigs in which they’re essentially paid for not doing anything…”  The ban “applies to Hopkins’s medical school, hospitals and clinics”.   It also “prohibits gifts, entertainment or food — regardless of value — from drug and medical device companies.”

As for consulting relationships, the policy says that payments that are “without commensurate associated duties are considered gifts and are prohibited.”

According to the Health Blog, Hopkins representatives do not “believe it has a problem with …’sham’ consulting arrangements, but they’ve been a subject of concern around the country.”  For there doctor’s sake, one would hope not since that might be a bit more problematic than a meal or gift, no?

From the policy:

[On Gifts:]To avoid the risk of conscious or subconscious bias in decision-making, it is the Johns Hopkins Medicine policy that faculty and staff, employees, students, trainees, and volunteers may not accept gifts or entertainment (see below for food and meals), regardless of value ***

[On Consulting Arrangements:] Consulting arrangements involving personal compensation without commensurate associated duties are considered gifts and are prohibited. Specific policies regarding outside consulting are set forth in the School of Medicine’s policy on conflict of commitment and in JHM organizations’ personnel policies. ***

[On Food/Meals]: With certain exceptions, outlined below, industry-supplied food and meals are considered personal gifts and will not be permitted and may not be accepted at any JHM member organization site, in connection with activity conducted under the auspices of or using the name of any JHM member organization or in the context of professional activity off-site. ***

[On Unrestricted Gifts to Instituti0n:] Through unrestricted gifts, industry generously supports the educational, research, and patient care missions of Johns Hopkins. Gifts must be made to the University or JHHS and deposited in a departmental account.  There may be no quid pro quo, nor any limitations nor conditions placed on gifts that are inconsistent with Fund for Johns Hopkins Medicine policies and applicable regulations.***

[On Samples:] The practice of accepting free pharmaceutical samples risks interference with one’s prescribing practices since industry representatives often provide the newest and most costly drugs. Therefore, free pharmaceutical samples and vouchers for free pharmaceutical samples may not be accepted.***

[On Access by Pharma Reps:] [A]ccess by pharmaceutical, medical testing and other industry representatives to individual physicians must be restricted to non-patient care areas. Access will be permitted only on invitation from a physician, nurse, pharmacist, respiratory therapist, or other professional healthcare staff member.***

[On Speaking Gigs:] Faculty members may speak at an industry-sponsored program only if the faculty member retains full control and authority over professional material the faculty member presents and does not allow such communications or presentations to be subject to prior approval by any commercial interest other than approval for the use of proprietary information.

via Johns Hopkins Bans Free Drug Samples, Gifts from Industry – Health Blog – WSJ.

Filed under: AKS, Compliance Programs, Conflicts of Interest, Health Law, , ,

The New Tarasoff? 6th Circuit OKs Hospital Suit Over Ax-Wielding Ex-Patient | ABA Journal – Law News Now

In Moses v. Providence Hospital and Medical Ctrs the Sixth Circuit federal court of appeals finds that the Emergency Medical Treatment and Active Labor Act (“EMTALA”), 42 U.S.C. § 1395dd gives hospitals a duty to third parties concerning patients that are admitted and then not appropriately treated and stabilized for a mental illness who later go on to harm the third party.  In Moses, a husband presents to the hospital emergency room with his wife, having severe headaches, muscle soreness, high blood pressure, vomiting, slurred speech, disorientation, hallucinations and delusions.  According to his wife he is demonstrating threatening behavior.  The man is clearly screened, although there is a dispute as to whether the physician involved concluded that the husband had an emergency medical condition.   He was admitted for testing and observation.  He was discharged four days later.  There is some evidence in the record that he was to be admitted to the psych unit, although other evidence suggest he had medically stabilized and desired to leave, although the wife was still afraid of him.  The husband, ten days after his discharge, killed his wife.

The defendant hospital’s case is dismissed in summary judgment at the district level.  The hospital contends that (1) the defendant lacked standing because only the individual patient who seeks treatment at the hospital has standing under EMTALA; and (2) that EMTALA imposes no further obligation on a hospital once the hospital has admitted a person as an inpatient.

The court, discounting some legislative history as not controling, and other judicial decisions that have held that relatives of individuals do not have standing, says that a plain reading of the statute requires that any individual who suffered an actual personal injury due to the EMTALA violation may bring a claim against the hospital.  Because this is a third party that suffered actual person injury by the hospital’s allged injury, the court did not think that Zeigler v. Elmore County Health Care Auth., 56 F. Supp. 2d 1324 (M.D. Ala. 1999) (looking to the legislative history of EMTALA, holding that a mother cannot maintain an EMTALA action for a violation related to her daughter’s medical condition) was on point.  The court acknowledges that “our interpretation of the civil enforcement provision may have consequences for hospitals that Congress may or may not have considered or intended. However, our duty is only to read the statute as it is written, as we have in our past analysis of EMTALA.”

The court also holds that the hospital’s obligations do not end upon admission of the patient as an inpatient.  This can be a thorny issue for hospital, but most hoped with the Centers for Medicare and Medicaid Services (“CMS”) new rules,  a hospital’s EMTALA obligations upon admitting an individual as an inpatient. 42 C.F.R. § 489.24(d)(2)(i).  The Moses court acknowledges that the rules state that “[i]f a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual.”  But the Moses court finds that this does not support the summary judgement because it was (1) enacted after the cause of action accruing in this case, and, more importantly (2) “[t]he CMS rule appears contrary to EMTALA’s plain language, which requires a hospital to ‘provide . . . for such further medical examination and such treatment as may be required to stabilize the medical condition[.]'”  The court pretty much lays down the gauntlet to hospitals: “a hospital may not release a patient with an emergency medical condition without first determining that the patient has actually stabilized, even if the hospital properly admitted the patient.”

This is a particularly remarkable case.  The allusions to the famous Tarasoff case may be overly broad — but I am sure there will be much more written about it.

Filed under: CMP, EMTALA, Health Law, , , ,

Vital Signs – Children – Early Swim Lessons May Reduce Drowning – NYTimes.com

In its Vital Signs article, the New York Times reports on a study (Arch Pediatr Adolesc Med. 2009;163(3):203-210) appearing in the The Archives of Pediatric & Adolescent Medicine, which looked at drowning deaths of children 1 to 19 in six states over two years.  Researchers in the study compared swimming experience of the victims with that of similarly aged children in the same county.  They found that swimming lessons did not increase the drowning risk for younger children and, in fact, seemed to decrease it.

Good to keep in mind; looking at the abstact, the association was noted as not being terribly robust.  However, some had speculated that early childhood swimming lessons might actually increase downing risk, by reducing the fear of water in young children.

I’ll keep this article in mind as Brookie and I get into the water at 8:45am on Saturdays this spring for a little daddy and me swimming lessons.  She’s a fish like her sister.

Filed under: Uncategorized

Op-Ed Columnist – Greed and Stupidity – NYTimes.com

Brooks believes that there are two overriding narratives that we must pick from to explain the current mess: (1) evil oligarchs took over the financial sector and lubed the wheels of power to allow them to get too big and too leveraged, (2) bankers suffered from an extreme lack of epistemological modesty.

There are many theories about what happened, but two general narratives seem to be gaining prominence, which we will call the greed narrative and the stupidity narrative…The best single encapsulation of the greed narrative is an essay called “The Quiet Coup,” by Simon Johnson in The Atlantic…Wall Street got huge. As it got huge, its prestige grew. Its compensation packages grew. Its political power grew as well… The result was a string of legislation designed to further enhance the freedom and power of finance… There were major increases in the amount of leverage allowed to investment banks…The U.S. economy got finance-heavy and finance-mad, and finally collapsed…In short, he argues, the U.S. financial crisis is a bigger version of the crises that have afflicted emerging-market nations for decades. An oligarchy takes control of the nation. The oligarchs get carried away and build an empire on mountains of debt. The whole thing comes crashing down.

The stupidity part of the equation is less paranoid, but just as disturbing:

The second and, to me, more persuasive theory revolves around ignorance and uncertainty. The primary problem is not the greed of a giant oligarchy. It’s that overconfident bankers didn’t know what they were doing… Many writers have described elements of this intellectual hubris… To me, the most interesting factor is the way instant communications lead to unconscious conformity… global communications seem to have led people in the financial subculture to adopt homogenous viewpoints. They made the same one-way bets at the same time…Jerry Z. Muller wrote an indispensable version of the stupidity narrative in an essay called “Our Epistemological Depression” in The American magazine. What’s new about this crisis, he writes, is the central role of “opacity and pseudo-objectivity.” Banks got too big to manage.

He believes that the latter is the the more compelling explanation, and cautions that if policy-makers believe it is the first, we might over-regulate by restructuring the financial sector.  In other words, he cautions against exchanging the hubris of Washington restructuring for the hubris of Wall Street.

The greed narrative leads to the conclusion that government should aggressively restructure the financial sector. The stupidity narrative is suspicious of that sort of radicalism. We’d just be trading the hubris of Wall Street for the hubris of Washington. The stupidity narrative suggests we should preserve the essential market structures, but make them more transparent, straightforward and comprehensible. Instead of rushing off to nationalize the banks, we should nurture and recapitalize what’s left of functioning markets.

He argues that we need regulatory controls to (1) ensure transparency, (2) reinitiate the separation between “savings banks, insurance companies, brokerages and investment banks”, and (3) ensure that the banks don’t get “too big.”

Hey, I’m in favor of all that.  But what other “restructuring” is really being contemplated?  Aren’t these the most serious and likely regulatory paths?  And when you are constraining growth,  forcing the downsizing of banking entities, or restricting what types of businesses can be integrated, isn’t that fundamentally about the “structure” of the financial sector?

Brooks contends that “one has to choose [among the two narratives] a guiding theory.”  But I don’t think I agree.  I think that both narratives get it partially right, and I think that Brook’s take on the correct regulatory outcome supports that thinking.   Many of the entities got too big to fail, the banking sector and policy-makers were complicit in both de-regulation and allowing this incredible growth of these huge transnational institutions, and these institutions created new markets with new instruments that looked like stocks and looked like insurance but were not regulated like stocks or insurance.   In the end, we (the bankers, the quasi-insurers, our policy makers, our federal reserve, our Congress, and ultimately all of us) were too stupid (or at least ignorant of history) to realize markets like these will cause systemic risk that can cause the whole house to crash down.  No pun intended.  The only way to address this systemic risk is like what came out of the Great Depression.  That is, a regulatory regime that provides transparency and forces individuals as well as institutions to have sufficient assets to secure the leverage that they have taken on.  This might be a gross simplification; the regulatory regime will be far more complex; but I think the principles are very much the same.

via Op-Ed Columnist – Greed and Stupidity – NYTimes.com.

Filed under: Uncategorized, , , , , ,

Op-Ed Columnist – Car Dealer in Chief – NYTimes.com

I think that Brooks has it wrong this time.  I agree that GM cannot restructure itself out of its current situation.  I agree that the Bush administration punted.  I agree that they should have — there needed to be preparation for the imminent bankruptcy.  I also disagree that this one has to remain a political football with Congress or the administration micromanaging GM’s bankruptcy process.   The administration needs to turf this to a real bankruptcy process and then get out of the way.  At the end of the line, it’s a fight between the financial stakeholders, not the politicians.  Throw the bondholders, unions, dealerships and other creditors into the pit (atop the corpse of shareholder equity) and see how it works out.

For 30 years, G.M. has been restructuring itself toward long-term viability. For all these years, G.M.’s market share has endured a long, steady slide…When the economy cratered last fall, the professionals at G.M. went into Super-Duper Restructuring Overdrive… The Bush advisers decided in December that bankruptcy without preparation would be a disaster. They decided what all administrations decide — that the best time for a bankruptcy filing is a few months from now, and it always will be…Today, G.M. and Chrysler have once again come up with restructuring plans…But this, President Obama declares, is G.M.’s last chance. Honestly. Really.No kidding…And yet by enmeshing the White House so deeply into G.M., Obama has increased the odds that March’s menacing threat will lead to June’s wobbly wiggle-out.  The Obama administration and the Democratic Party are now completely implicated in the coming G.M. wreck…The Midwestern delegations, swing states all, will pull out all the stops to prevent plant foreclosures. Unions will be furious if the Obama-run company rips up the union contract… The most likely outcome, sad to say, is some semiserious restructuring plan, with or without court involvement, to be followed by long-term government intervention and backdoor subsidies forever…It would have been better to keep a distance from G.M. and prepare the region for a structured bankruptcy process. Instead, Obama leapt in. His intentions were good, but getting out with honor will require a ruthless tenacity that is beyond any living politician.

via Op-Ed Columnist – Car Dealer in Chief – NYTimes.com.

Filed under: Personal Posts, , , , , , , , ,

High-End Health Care in the Boardroom – DealBook Blog – NYTimes.com

Spouse travel at Footlocker, out of state physicals at Stryker and executive physicals at Norfolk Southern.

Directors and executives at Norfolk Southern may be among the healthiest out there, judging from the proxy that the company filed Tuesday.  That’s because the railroad operator covers up to $10,000 a year in medical expenses for each nonexecutive director as well as a group of top executives, including Charles W. Moorman IV, its chairman and chief executive. Mr. Moorman spent $4,800 on his physical last year and another $4,800 in 2007. Four other executives spent between $3,800 and $4,800 on the perk.

via High-End Health Care in the Boardroom – DealBook Blog – NYTimes.com.

Filed under: Concierge Medicine, Conflicts of Interest, Executive Compensation, Health Law, , ,

Footing the Bill for a Spouse’s Travel – DealBook Blog – NYTimes.com

Thank goodness I don’t have to travel much anymore.  But if I do, I want to be the chief executive at Footlocker.

According to Foot Locker’s preliminary proxy statement, “Mr. Halls’s wife may accompany him on up to eight business trips each fiscal year at the company’s expense.” …The company says the perk is an exception to its normal policy on spousal travel, because of Mr. Halls’s “extensive international travel obligations.” …Last year, Mr. Halls’s spousal travel reimbursement cost the company $123,000 plus another $112,000 to cover the taxes that would have been owed on the perk. In the filing, the company notes that starting this year, it will no longer cover the gross-up.

via Footing the Bill for a Spouse’s Travel – DealBook Blog – NYTimes.com.

Filed under: Compliance Programs, Conflicts of Interest, Health Law, Personal Posts, , ,

Top 25 Lawyers Behind the Deals of the Year – DealBook Blog – NYTimes.com

Wow.  It’s a sign of the times when the vast majority of notable deals are hightlighted as non-traditional M&A related to bailouts and collapses! Remarkable times.

Only six of the dealmakers on the list this year were recognized for their involvement in conventional mergers-related deals (most are at the bottom of the list except for those involved in InBev’s purchase of Anheuser-Busch and Mars’s purchase of Wrigley). The various distressed deals and government–brokered mergers topped the list…

Here were the deals noted in American Lawyer:

1. Bank Bailouts: H. Rodgin Cohen, Sullivan & Cromwell

2. Bank of America’s Merrill Lynch acquisition: Edward Herlihy, Wachtell, Lipton, Rosen & Katz

3. Lehman Bankruptcy: Harvey Miller, Weil, Gotshal & Manges

4. TARP: Lee Meyerson, Simpson Thacher & Bartlett

5. A.I.G. Bailout: Michael Wiseman, Sullivan & Cromwell

6. IndyMac Purchase: Paul Glotzer, Cleary Gottlieb Steen & Hamilton

7. InBev’s Anheuser-Busch Acquisition: Francis Aquila, Sullivan & Cromwell

8. Fannie, Freddie Conservatorships: Harold Novikoff, Wachtell, Lipton, Rosen & Katz

9. FGIC Rescue: Corinne Ball, Jones Day

10. Federal Interventions: Thomas Baxter Jr., Federal Reserve Bank of New York

11. Calpine, Solutia Bankruptcies: Richard Cieri, Kirkland & Elli

12. KazMunayGas Pipeline Renegotiation: George Kahale III, Curtis, Mallet-Prevost, Colt & Mosle

13. Mars’s Wrigley Acquisition: John Finley, Simpson Thacher & Bartlett

14. Latin American Project Financings: Cynthia Urda Kassis, Shearman & Sterling

15. A.I.G. Bailout: Marshall Huebner, Davis Polk & Wardwell

16. Visa I.P.O.: S. Ward Atterbury, White & Case

17. Independent Director Representations: Robert Joffe, Cravath, Swaine & Moore

18. Vallejo Bankruptcy: Marc Levinson, Orrick, Herrington & Sutcliffe

19. Clearwire Asset Acquisition: Joshua Korff, Kirkland & Ellis

20. Sirius-XM Merger: Joe Sims, Jones Day

21. Verizon Wireless’s Alltel Acquisition: Jeffrey Rosen, Debevoise & Plimpton

22. Triarc’s Wendy’s Acquisition: Paul Ginsberg, Paul, Weiss, Rifkind, Wharton & Garrison

23. Citigroup Bailout: George Bason Jr., Davis Polk & Wardwell

24. Washington Mutual Bankruptcy: Marcia Goldstein, Weil, Gotshal & Manges

25. A.I.G. Bailout: Eric Dinallo, New York State Insurance Department

via Top 25 Lawyers Behind the Deals of the Year – DealBook Blog – NYTimes.com.

Filed under: Personal Posts, , , , , , , ,

Signs of Pessimism Ahead of Tulane M.&A. Conference – DealBook Blog – NYTimes.com

In advance of the Annual M&A conference in Tulane, a survey of participants revealed significant pessimism concerning the near term future of transactional work.   These are the guys that ostensibly have their ear to the ground regarding economic activity.  According to the Deal Book Blog, it’s better than 50% that we won’t recover to prior transactional levels (i.e., certainly not economic levels) of 2007 for five years:

69 percent of respondents believe it will take up to five years to return to the level of M.&A. activity seen in 2007 — up sharply from the 42 percent who shared that view in 2008. Meanwhile, only 29 percent of respondents maintain there will be signs of recovery in a year to 18 months — down from 52 percent last year.

via Signs of Pessimism Ahead of Tulane M.&A. Conference – DealBook Blog – NYTimes.com.

Filed under: Personal Posts, , ,

How to Save General Motors

In its Dealbook Blog, the New York Times presents a solution by several leading bankruptcy attorneys.  GM has an admitted $100 billion negative net worth.  It cannot survive as structured and it cannot be restructured without some strong decision-maker that can cram very unpleasant concessions down the throats of stakeholders.  In any other scenario, that’s a bankruptcy process.  The authors recognized that this is not an ‘ordinary’ bankruptcy, but it is not without precedent.  They also observe:

The current public debate is misplaced over whether or not bankruptcy is the solution to G.M.’s problems. There is a public misconception about what bankruptcy means for a business enterprise. Bankruptcy can mean liquidation, or it can be a means of renewal, taking a financially distressed business and creating a viable company by restructuring or eliminating burdensome contracts, reducing debt, and securing new financing. Chapter 11 is such a process; it is flexible; and it can, and must for G.M., be quick. The paramount goal of the G.M. bailout should be the expedient creation of a viable G.M. Core. A sale to a G.S.E. as part of a Chapter 11 proceeding seems to us to be exactly the process to achieve that goal.

It is worth a read.  And this (or a variation of it) is what’s going to happen, eventually, even if the economy suddenly bottoms out and begins a climb back upward.  There’s no political process to solve this but for unending government cash flows to these insolvent entities.  And I don’t think the taxpayers have the stomach for the kind of cash that will require over the next six months even.  Further, Obama’s axing of the CEO of GM, GM’s recent change of tune regarding its considering bankruptcy, the strict time lines for GM to strike its own deal as set down by the administration, as well as Obama’s commitment that warranties would be backed by the full faith and credit of the US (which was a main argument by the automakers regarding why the could not go into Chapter 11) are not inconsistent with some bankruptcy process being the end game.

See also U.S. Plan Sees Easing of G.M. to Bankruptcy from the New York Times DealBook on

via Another View: How to Save General Motors – DealBook Blog – NYTimes.com.

Filed under: Personal Posts, , , , , , ,

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