Sermo CEO on a mission...

The CEO of Sermo - a leading online community for physicians is now in a fight with the AMA and Doctors for America - an organization run by some friends of ours supporting the Obama health care reform effort.

Details at
Sermo CEO: AMA 'screwing' physicians - Modern Medicine Community Blog post and at the bottom of this email (a facebook message from DFA)

An interesting point raised in the first article is that the AMA receives a lot of money for the CPT coding system - a fact I did not know about:

"The AMA receives approximately $70 million in 'licensing fees' from anyone who needs to use those codes. Add to that insurance companies (who pay the AMA many of those millions) who can use the CPT coding system to further their own gains at the expense of the physicians, and it starts to make you realize why CPT codes have been so conveniently left out of the current debate."

The CEO of Sermo also supposedly went onto CNBC early this week saying that physicians opposed health care reform based on a survey they did on their online community.

I had blogged about this survery earlier this month. It seems spurious at best, though I agree with the general premise that the AMA does not speak for all physicians. However, I'm not sure what the motivation is for the CEO of Sermo - is he trying to supplant the AMA as the "voice of physicians"? It all seems like a bizarre sideshow about doctor power instead of the real debates on health care reform.

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From DFA on facebook:

Dear Friends,

(If you haven't already, come be a fan of our Facebook Page: http://www.facebook.com/pages/Doctors-for-America/94559877688?ref=ts for updates on the latest in health reform and other fun.)

The CEO of Sermo plans to announce on national television that doctors oppose health reform legislation.

**Don't let him speak for you. Click to take our quick poll today!**
(www.drsforamerica.org/pol

l/house.php)

The claim is based on a misleading survey of Sermo members. It will be unveiled on Monday, July 27th on CNBC and shared with Congress. However, we know from the comments and actions of thousands of fellow physicians across the country that doctors want and need health reform this year.

**Do you have 2 minutes? Help us tell the truth about reform today!**
(www.drsforamerica.org/poll/house.php)

Doctors are the most trusted voice in health reform - you can make the difference. Just this past week, Doctors for America members in 30 states picked up their phones to call Congress in support of reform, and physicians from Kansas to Wyoming, from Alaska to New Mexico, have signed up to volunteer. You can help today with a quick poll on whether you like various aspects of the reform bill.

**Answer this quick poll today!**
(www.drsforamerica.org/poll/house.php)

After you have voted, please send this link to 5 friends. We will give preliminary results to CNBC and other media early Monday morning. We have made great progress toward achieving meaningful health reform, but those gains are only temporary until reform legislation lands on the President's desk. We need to do everything we can to help make sure we have good reform and that it passes this year. I know we can count on you.

Thanks,
Alice

Side-by-Side Comparison of Major Health Care Reform Proposals by the Kaiser Family Foundation

This link contains an interesting tool that allows Side-by-Side Comparison of Major Health Care Reform Proposals.
It is from the Kaiser Family Foundation.

"Achieving comprehensive health reform has emerged as a leading priority of the President and Congress. President Obama has outlined eight principles for health reform, seeking to address not only the 45 million people who lack health insurance, but also rising health care costs and lack of quality. In Congress, a number of comprehensive reform proposals have been announced as the debate proceeds over how to overhaul the health care system.

This interactive side-by-side compares the leading comprehensive reform proposals across a number of key characteristics and plan components. Included in this side-by-side are proposals for moving toward universal coverage that have been put forward by the President and Members of Congress. In an effort to capture the most important proposals, we have included those that have been formally introduced as legislation as well as those that have been offered as draft proposals or as policy options. This side-by-side offers a summary of the major components of these proposals; detailed descriptions of provisions relating to the Medicare and Medicaid programs can be found online. It will be regularly updated to reflect changes in the proposals and to incorporate major new proposals as they are announced."

ACP moving towards endorsing health care reform

We have talked previously about our frustrating with the American Medical Association (AMA). Many physicians do not believe that the AMA speaks "on their behalf."

On the other hand, most physicians place more stock in their respective specialty association. Since medicine is so diverse, the support needs are highly specialized by specialty and these associations cater specifically to the specialties needs. As an internist, I'm more keen to see what my association - the American College of Physicians (ACP) - has to say on the matter.

I received an email from my local ACP president which is fairly supportive of the current House bill. I'm not really following closely what the AMA has to say on the bill, but I'm glad to see that the ACP is thinking about the legislative process in a sane manner.

The last two paragraphs of this post I think are the constructive message for physicians - be a part of the process, instead of vilifying ourselves - and let's try to make this reform effort a step in the right direction.

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TO: ACP Key Congressional Contacts

FROM: Bob Doherty, Senior Vice President, Governmental Affairs and Public Policy

SUBJECT: ACP's views on H.R. 3200, the America's Affordable Health Choices Act of 2009, and efforts to organize opposition to it

Yesterday, the chairmen of the three House committees with jurisdiction over health care reform introduced the America's Affordable Health Choices Act of 2009, H.R. 3200. (The Senate Health, Education, Labor and Pensions Committee has introduced its bill; we are still awaiting a bill from the Senate Finance Committee, which may be released within days). I want to update you on why the American College of Physicians believes that H.R. 3200 merits internists' support, even as we continue to work for improvements through the legislative process.

I know this e-mail is long, but I encourage you to take the time to read through it. It is critical that we continue to work together as Congress moves forward on legislation so critical to patients and you, the physicians who care for them.

The bill is closely aligned and consistent with ACP policies on our top priorities for health reform as developed through our policy committees and approved by the Board of Regents (with input from the Board of Governors and ACP councils). Specifically:

Coverage: The bill creates a pluralistic framework so that all Americans will have access to affordable health insurance coverage, similar to ACP's own seven year plan. It will give eligible persons a wide choice of health plans, including the option of maintaining their current health plan. ACP supports the bill's proposals to reform the insurance industry so that coverage no longer is out of reach for people who have pre-existing conditions or who develop an illness while insured. We support sliding scale tax credits, coverage of evidence-based preventive services with no cost-sharing, and expansion of Medicaid to cover the poor.

ACP does not have policy on the bill's proposal to finance coverage through an income tax surcharge on higher income persons. I anticipate, though, that there will be major changes in the tax and financing mechanisms as legislation makes its way through the House and then has to be reconciled with the Senate, which seems disinclined to rely on an income tax surcharge. The College supports the bill's shared responsibility for funding health care reform, including requirements that employers contribute to coverage and that individuals obtain coverage once affordable options are available to them.

Workforce: The bill would establish a national health workforce policy to help set goals and policies to achieve a sufficient and optimal number and distribution of physicians and other clinicians. It includes policies, recommended in ACP's own policy paper on solutions to the primary care workforce crisis, to increase the numbers of physicians in primary care internal medicine, family medicine and geriatrics, including increased funding and creation of new pathways to provide scholarships and loan forgiveness to primary care physicians who agree to practice in areas of need and policies to facilitate increased training in office-based primary care practices. We also agree on the need to increase GME training positions for primary care specialties as the bill proposes.

Sustainable Growth Rate: The bill would eliminate the accumulated Medicare SGR payment cuts, and by doing so, pave the way for Congress to replace the annual cycle of Medicare payment cuts with a new update system. The bill provides a new framework for future updates that allow for spending on physician services to increase at a rate greater than GDP, and creates a higher spending baseline target for evaluation and management and preventive services, including those associated with primary care.

Primary Care Payment Increases: The bill provides for an additional 5% increase, beginning in 2011, for designated evaluation and management services by general internists and other primary care physicians. The primary care bonus is increased to 10% for designated services in Health Professional Shortage Areas. The bill also would increase Medicaid payments for primary care to be equivalent to Medicare.

Although ACP continues to believe that a larger primary care bonus is needed-we have asked for at least 10% in all areas the country, 15% in health professional shortage areas, we believe that the recognition of the need to increase payments for primary care is an important step forward, especially combined with other changes in the bill to support primary care.

Patient-Centered Medical Home: The bill also provides dedicated funding to pilot-test, on a national scale, the idea of paying physicians for care coordination in a qualified Patient-Centered Medical Home. ACP will continue to provide Congress with ideas on strengthening the payment and delivery system reforms to accomplish the goals of increasing the numbers of physicians in primary care fields.

Comparative Effectiveness Research (CER): The College strongly supports the proposal to fund independent, transparent and evidence-based research on the comparative effectiveness of different treatments to inform physician-patient decision-making.

In addition to its strong correlation with ACP policy and priorities, H.R. 3200 provides substantially more funding to physicians at a time when most other providers are facing deep cuts, according to preliminary estimates from the Congressional Budget Office.

$228.5 billion to eliminate accumulated SGR cuts
$1.6 billion for the PQRI (positive incentives only, no penalties for non-reporting)
$1.3 billion to make the geographic floor on Medicare payment permanent
$5 billion for the primary care bonus
$1.8 billion for medical home demonstrations

No bill is perfect, but the House bill delivers on our major priorities in a way that is remarkably consistent with ACP policies, policies that were developed by the College's leadership over many years and always guide how we-leadership, Key Contacts and staff-advocate for ACP's internal medicine physicians and your patients.

Despite all of the positive elements in H.R. 3200, there is an effort being made in many states to persuade physicians to oppose the bill. You should be aware of the arguments being made by opponents and how I respond to them:

• Opponents argue that the "public plan option" included in H.R. 3200 would lead to the destruction of private insurance and government-run health care.
This is an issue that has elicited strong but divided opinion among ACP members. Some internists have expressed practical and philosophical concerns about the public plan, while others have said that they believe a public plan is essential.

ACP policy says: a public plan could appropriately be offered, along with qualified private plans, if participation in the public plan is voluntary, if it competes on a level playing field with private insurers, and if it is not locked into Medicare's payment rates. Under H.R. 3200, physician and patient participation in the public plan would be voluntary. The public plan would have to pay for itself through premiums collected, rather than being funded from the U.S. Treasury, to help place it on a level playing field with private insurers.

ACP has advised the House that we are concerned that the House bill would have a public plan use Medicare rates (Medicare plus 5% for physicians who accept both Medicare and the public plan) for its first three years. The College will continue to strongly advocate that the public plan be required to pay competitively with private insurers. (The Senate HELP bill, for instance, would benchmark the public plan's rate to the average offered by qualified private plans, so there will be opportunities to address how the public plan sets its rates later in the legislative process).

Opponents also suggest that H.R. 3200 would prohibit private contracting and balance billing, but there is nothing in the law that prohibit existing rights for physicians and patients to enter into voluntary contracts. Like Medicare, however, physicians who choose to take care of patients in the public plan would have to accept limits on charges, similar to the Medicare participating and non-participating physician agreements. No physician would be mandated to accept the public plan and its rates.

The idea that the public plan would destroy private insurance is also not supported by expert analysis. The Congressional Budget Office notes that because physician participation in the public plan is voluntary, and payments are likely to be lower than payments under private insurance plans, it is difficult to estimate how many people would enroll in the public plan. The CBO suggests that enrollment in a public plan, at full implementation, could be as many as 8 or 9 million people out of the estimated 30 million who would get coverage through the exchange, many of whom though are currently uninsured, but even so, this would mean that most people in the exchange would be covered under private insurance. CBO also estimates that the vast majority of persons-164 million, an increase of two million persons compared to current law-would be covered by employers.

• Opponents argue that CER would lead to rationing of care by government bureaucrats.
Actually, the bill's CER provisions are completely consistent with ACP's support for an independent, transparent and evidence-based process to conduct research on the clinical effectiveness of different treatments to inform clinical decision making. There is nothing in the bill that allows costs to be used to deny care. The research would be conducted by physicians and other scientists in agencies, like the National Institutes of Health and the Agency for Health Care Research and Quality, not by government bureaucrats. Coverage decisions would still be made as they are today, but instead would be informed by the best available clinical evidence instead of by criteria that often is not guided by science.

Now it's time to think politics.

To try to influence Congress to consider our ideas to improve the bill, we will be far more effective if internists support all of the positive policies in the bill. We want to continue to be invited to the table and not to have to fight to be there. Destructive opposition will effectively remove us from being invited and place at great risk all of the positive changes that the bill would bring about -including the coverage, workforce, elimination of Medicare SGR cuts, and payment reforms to support primary care.

To this point, the overwhelming majority of physicians have supported health care reform. Let's stay together and let other stakeholders bloody themselves. We still have the senate bills to work through, votes to seek and a Senate-House conference committee to work with. We need, and hope for, your active participation throughout.

Rationing Health Care (don't we already?)

Prof. Peter Singer from Princeton University had a great piece on the ethics of rationing health care in Sunday's NYT Magazine.

http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html

We already ration health care by prioritizing health care delivery for the relatively wealthy.

The question is not whether to ration health care. The question is whether the wealthy are willing to accept rationing of their health care for the general good.

Randomized Controlled Trial Shows Circumcision Does Not Prevent Male-To-Female HIV Transmission - Kaiser Global Health

Global health folks - what's your thoughts on this recent Lancet article?

Randomized Controlled Trial Shows Circumcision Does Not Prevent Male-To-Female HIV Transmission

I was following the literature about two years ago, and had blogged about this previously. This study I could see be used to detract from circumcision programs - and I find the literature increasingly confusing. What's your take on it?

Collins and Brooks on health care reform

Partisan Health Care Politics - The Conversation Blog - NYTimes.com

The conversation between Brooks and Collins is right on point. The bills being developed in Congress do not fundamentally shift the incentives in health care. We are cutting prices which really doesn't do anything to change doctor's incentives. If anything, they are more likely to medicalize their patients more... for example, Japan has been trying to control health care costs for the last two decades, and they have used prices as their main lever. Consequently since Revenue = price times quantity, all that Japanese physicians have done is reduce the time they see patients, and see more patients per session (raised quantity since prices are down, to maintain their revenue).

I like what Collins and Brooks argue for - a strong MedPAC that has teeth. Their reports are great - much like NICE in the NHS / UK - but just like NICE, there's no impetus for congress to act on MedPAC ideas.

I'm becoming more of the mind that health care needs strong intelligent technocrats, and not partisans who infuse ideology into difficult policy negotiations. the conversation between collins and brooks highlights that there are many principles that folks from both sides of the aisle can agree on.

Taxing to pay for health care - is it necessary?

The House Democrats have introduced their proposal for health care reform.

The tax raises are minimal at first:

"Starting in 2011, a family making $500,000 would have to pay $1,500 of additional income tax to help subsidize coverage for the uninsured. A family making $1 million would have to pay $9,000."

This is not a tremendous amount of money. It does have the potential to rise substantially if the government is not able to "bend the cost curve" and decrease Medicare and associated costs.

What I upsets me a bit is that we are even looking at tax raises. Don't get me wrong - I have no issues paying higher taxes - but the fact that we spend over $2 trillion and we have to raise even MORE money for health care seems ridiculous.

The issue in our health care system is about paying for health care value - not paying for more health care regardless if it has value or not. We have discussed Michael Porter's NEJM article previously on this board - but he says it best:

"What we need now is a clear national strategy that sets forth a comprehensive vision for the kind of health care system we want to achieve and a path for getting there. The central focus must be on increasing value for patients — the health outcomes achieved per dollar spent. Good outcomes that are achieved efficiently are the goal, not the false "savings" from cost shifting and restricted services. Indeed, the only way to truly contain costs in health care is to improve outcomes: in a value-based system, achieving and maintaining good health is inherently less costly than dealing with poor health.

True reform will require both moving toward universal insurance coverage and restructuring the care delivery system. These two components are profoundly interrelated, and both are essential. Achieving universal coverage is crucial not only for fairness but also to enable a high-value delivery system. When many people lack access to primary and preventive care and cross-subsidies among patients create major inefficiencies, high-value care is difficult to achieve. This is a principal reason why countries with universal insurance have lower health care spending than the United States. However, expanded access without improved value is unsustainable and sure to fail. Even countries with universal coverage are facing rapidly rising costs and serious quality problems; they, too, have a pressing need to restructure delivery."

And again, this is the issue - cost containment and driving health care value.

Survey on the AMA

Sermo - an online physician community - recently polled physicians on their opinions on the AMA - a topic we have talked about on this board.

Survey results

The survey results are cut bizarrely. But with that said, taking a few leaps in analytics, it looks like even 50% of the people who are members of the AMA believe the AMA does not speak for them, and only a third of AMA members believe that the AMA accurately reflects their opinions as a physician.

I guess people join for the free JAMA subscription. Not for their lobbying efforts...

New NIH head

Wanted to forward along the article some of us were discussing at dinner last night.

http://www.nytimes.com/2009/07/09/health/policy/09nih.html?_r=1&ref=health

"There are two basic objections to Dr. Collins. The first is his very public embrace of religion. He wrote a book called “The Language of God,” and he has given many talks and interviews in which he described his conversion to Christianity as a 27-year-old medical student. Religion and genetic research have long had a fraught relationship, and some in the field complain about what they see as Dr. Collins’s evangelism.
The other objection stems from his leadership of the Human Genome Project, which is part of the N.I.H. Although Dr. Collins was widely praised in 2003 when the effort succeeded, the hopes that this discovery would yield an array of promising medical interventions have greatly dimmed, discouraging many. "

IOM and residency work hours

Recent article on IOM's new work hour suggestions

Report says no resident should work longer than a 16-hour shift, which should be followed by a mandatory five-hour nap period.

They don't reduce the overall number of hours that people work, but by introducing this, you effectively need to double your workstaff because somebody else will need to be around while the other doctor is taking their nap.

I understand the patient safety need - but by introducing siesta into residency training you'll be doubling handoffs (bad for patient care) and you'll need to increase workstaff (drives costs).

Sounds like a bad idea to me.

Dems leaning towards tax increases?

We all know that our health care system spends nearly double what other developed countries do, leaves many uninsured, and leads to worse outcomes. So the solution that many Democrats are leaning toward is....spending even more money. This is a total failure of leadership. Apparently they are too weak to stand up to key stakeholders - docs, hospitals, payors, pharma, and others - to bring costs under control. So rather than create a sustainable health care system, they will dump more money into it in order to expand it to cover more patients. They are looking to tax the wealthy to do this. I am not against taxing the wealthy per se, but it should not be necessary for health care reform. There is already enough money in the system to cover every man woman and child in this country, if we could spend that money more wisely. But that takes courage, innovation, creativity, and, above all, political will. It means axing or cutting the employer health plan tax deduction, reforming how docs and hospitals are paid, ending the subsidy for Medicare Advantage, funding comparative research - all things that would lead to wiser spending but potentially alienate some powerful interests. Obama needs to step up to the plate and spend some of his political capital to fix the system, rather than expand it.

Top articles on the financial crisis

Folks have asked me for the top resources to understand the financial crisis. Not directly related to the topic of this blog - but there is no doubt that the financial crisis has served as an additional impetus in driving health care reform here in the United States.

So here they are:

Nick Paumgarten: The Death of Kings

http://www.newyorker.com/reporting/2009/05/18/090518fa_fact_paumgarten


Michael Lewis: The End of Wall Street

http://www.portfolio.com/news-markets/national-news/portfolio/2008/11/11/The-End-of-Wall-Streets-Boom


Niall Ferguson: Planet Finance and The Age of Leverage

http://www.vanityfair.com/politics/features/2008/12/banks200812


Barry Eichengreen: The Last Temptation

http://www.nationalinterest.org/Article.aspx?id=21274

The Baseline Scenario

http://baselinescenario.com/financial-crisis-for-beginners/

Simon Johnson: The Quiet Coup

http://www.theatlantic.com/doc/200905/imf-advice

Krugman on Universal health care

Op-Ed Columnist - HELP Is on the Way - NYTimes.com: "a look at the U.S. numbers makes it clear that insuring the uninsured shouldn’t cost all that much, for two reasons.

First, the uninsured are disproportionately young adults, whose medical costs tend to be relatively low. The big spending is mainly on the elderly, who are already covered by Medicare.

Second, even now the uninsured receive a considerable (though inadequate) amount of “uncompensated” care, whose costs are passed on to the rest of the population. So the net cost of giving the uninsured explicit coverage is substantially less than it might seem."

A Doctor's Reflections on Health-Care Reform

It is articles like this - without data, and full of self-interested posturing, that gets me upset about physician perspectives on health care reform.

A Doctor's Reflections on Health-Care Reform - WSJ.com

The McAllen Problem

Rajiv pointed me to this article the other day - brutally on target, if you ask me. As one of my mentors once told me - doctors are finely tuned economic machines:

The McAllen Problem: The Baseline Scenario

What is the lesson of McAllen, Texas, the focus of Atul Gawande’s celebrated article (discussed here and here)? This is my attempt at an answer:

Currently, our health care system has high-cost and low-cost areas; the high-cost areas have no better outcomes than the low-cost areas. So theoretically we can solve our health care cost problem by making the high-cost areas behave like the low-cost areas.

However, the market incentives go in the other direction; the economically rational thing for providers (doctors, hospitals, etc.) to do is to run up procedures and thereby costs. It would be better if providers focused more on patient outcomes or organized themselves into accountable care organizations, as Gawande prefers; but there is no economic reason for them to do so. People are not magically going to become more altruistic overnight. Even shame has only a temporary effect on behavior. Here’s Gail Wilensky from a Health Affairs roundtable:

It’s only by being able to offer compelling evidence that it’s the physician that is the outlier relative to his or her peers, that the patients really aren’t different, and in fact they are not having better outcomes, that you are able to pull back physician behavior — although there seems to be a high recidivism rate.

(Emphasis added.)

In some ways McAllen isn’t the aberration; according to the old Chicago economics department, everywhere should be like McAllen.

Remember all the people who said that you can’t blame mortgage brokers and investment bankers for being greedy, because that’s how a capitalist economy works? Well, you could make the same defense for the McAllen doctors. We long ago stopped expecting lawyers and accountants to behave contrary to their economic interests; now we simply expect them to conform to the law and to certain professional codes of conduct, and otherwise make as much money as possible. Why should we expect anything different from doctors?

In a capitalist economy, the thing that is supposed to keep prices in check is the buyers. If someone offers me a product that costs more than it is worth to me, then I won’t buy it. But we can’t count on patients to play this role in health care, because there is no way to make patients internalize all of the costs of their care; they simply don’t have the money. Furthermore, most people don’t understand the health production function (the relationship between treatments and outcomes), so they don’t have the ability to select treatments that provide benefits that are worth their costs. (And, in many cases, it’s not obvious even to professionals that a treatment isn’t worth the cost; it’s only obvious when you look at the data in aggregate.)

What about payers (health insurers?) A “market” solution would be to change the reimbursement rates for different procedures – increase payment for things that doctors should do more of and reduce payment for things that doctors should do less of. Theoretically, payers should be doing this already. However, in the current situation, a private payer who tried to reduce the rates for popular, expensive procedures would find itself unable to attract providers. The only payer with any real negotiating power is Medicare. The private payers have little ability to control costs. Or, if they have the ability, they aren’t exercising it.

In short, prices will only go up. As a result, the cost of health insurance goes up, and the market finally kicks in in the crudest possible form: people who can’t afford it become uninsured. At some point, if we have enough uninsured people, the health care industry will hit a point where it cannot increase revenues anymore, because it has fewer and fewer paying customers.

The proposed public health insurance plan would have the power to negotiate lower rates with providers. That’s why some providers don’t like it. That’s also why private payers don’t like it; they would be at a cost disadvantage to the public plan. (They can live with Medicare because Medicare leaves them the entire under-65 market.) Maybe that’s unfair. But the current situation isn’t working.

By James Kwak

The Institute for Health Metrics and Evaluation (IHME)’s upcoming report, "Financing Global Health 2009"

But 12 of the 30 countries with the highest disease burden aren’t receiving as much aid as healthier, and, in some cases, wealthier countries

–Well-heeled donors, private corporations and average citizens sending money to their favorite charities are changing the landscape of global health funding, according to a new study by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington.

Press release: http://healthmetricsandevaluation.org/resources/news/2009/Jun_18_2009.html

The Lancet, Volume 373, Issue 9681, Pages 2113 - 2124, 20 June 2009 Financing of global health: tracking development assistance for health from 1990 to 2007 at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60881-3/fulltext

“…..The research shows that funding for health in developing countries has quadrupled over the past two decades – from $5.6 billion in 1990 to $21.8 billion in 2007. Private citizens, private foundations and non-governmental organizations are shifting the paradigm for global health aid away from governments and agencies like the World Bank and the United Nations and making up an increasingly large piece of the health assistance pie – 30% in 2007. However, health aid does not always reach either the poorest or unhealthiest countries.

The study, Financing of global health: tracking development assistance for health from 1990 to 2007, appears in the June 20th issue of The Lancet and provides the first ever comprehensive picture of the total amount of funding going to global health projects. It takes into account funding from aid agencies in 22 developed countries, multilateral institutions like the World Health Organization and hundreds of nonprofit groups and charities. Prior to this report, nearly all private philanthropic giving for health was unaccounted for, meaning that nearly a third of all health aid was not tracked.

Overall, poor countries receive more money than countries with more resources, but there are strong anomalies. Sub-Saharan Africa receives the highest concentration of funding, but some African countries receive less aid than South American countries with lower disease burdens – like Peru and Argentina. Of the 30 low- and middle-income countries with the most illness and premature death, 12 are missing from the list of countries that receive the most health aid, including Angola, Ukraine and Thailand.

"With no one tracking this massive growth in spending, it’s no wonder that some countries receive far more than their neighbors for no immediately apparent reason,” said Dr. Christopher Murray, professor of global health and director of IHME at the University of Washington, and co-author of the study. "We’re hoping that this attempt to count money that has never been counted before in a careful and consistent way will lead to greater transparency and better use of health resources.”Some small island nations with relatively healthy populations like Micronesia and the Solomon Islands receive more health aid per capita than disease-stricken countries like Niger and Burkina Faso. Mali and Colombia have about the same level of sickness, but Colombia receives three times as much health funding. The study also found that two of the world’s emerging economic super powers, China and India, receive huge amounts of health aid. “We don’t know exactly why some countries seem to be far outpacing other countries, but historical, economic and political ties appear to be a factor,” said Nirmala Ravishankar, an IHME research scientist and the study’s lead author. “Some of these small islands are former colonies of the countries now giving them aid, and, in other cases, health aid seems to coincide with defense spending or drug interdiction efforts. This is an area that begs for more research.”

Where the money is being targeted within those countries also merits more scrutiny. Based on the research for 2007, HIV/AIDS receives at least 23 cents out of every dollar going into development assistance for health. Tuberculosis and malaria received less than a third of that, even though the combined burden for those diseases is greater than that from HIV/AIDS in developing countries and despite promises by G8 countries that those diseases would receive more funding. At the same time, about a nickel out of every dollar channeled to health assistance goes to system-wide health support – like funding for new clinics, doctor training and prevention programs – which is an area that global health experts have clearly identified as a priority. The study also reveals other key findings:

• The scale-up of global health funding doubled from 1990 to 2001 and then doubled again by 2007.
• The growth has been driven largely by donations from the U.S. government and U.S.-based private charitable organizations. In sheer volume, the U.S. accounted for over 50% of total development assistance for health in 2007. But, in terms of the fraction of national income that becomes health aid, the U.S. trails Sweden, Luxembourg, Norway, and Ireland.
• The Bill & Melinda Gates Foundation tops the list of private foundations providing global health aid, making up nearly 4% of all health assistance in 2007.
• Food For The Poor, Population Services International and MAP International lead all non-governmental organizations (NGOs) in spending on health aid, each contributing more than $1 billion in health assistance from 2002 to 2006. Six of the top 10 NGOs are religious organizations.
• In-kind contributions, such as donated drugs, made up more than 90% of the revenues of some of these NGOs, and they made up more than 50% of their total overseas health expenditure for most years during the study period. Because donations of drugs from pharmaceutical companies are sometimes valued at current market prices, this has potentially resulted in an exaggeration of the magnitude of resources flowing via US NGOs.

More details will be published in The Institute for Health Metrics and Evaluation (IHME)’s upcoming report, Financing Global Health 2009, University of Washington, Seattle, WA, USA.

(N Ravishankar PhD, P Gubbins BA, R J Cooley MED, K Leach-Kemon MPH, Prof D T Jamison PhD, Prof C J L Murray MD); and Harvard Initiative for Global Health, Harvard University, Cambridge, MA, USA (C M Michaud MD)

Related Content:

• See the figures
• Download the slides (2.66MB ppt)
• Map the data on IHME's GIS tool

The Lancet, Volume 373, Issue 9681 - 20 June 2009 An assessment of interactions between global health initiatives and country health systems
Health Organization Maximizing Positive Synergies Collaborative Group
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60919-3/fulltext

Editorial: Who runs global health? http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61128-4/fulltext

What can be learned from data for financing of global health?
Peter S Heller, Paul H Nitze School of Advanced International Studies, The Johns Hopkins University, Washington
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61132-6/fulltext

Address at the high-level dialogue on maximizing positive synergies between health systems and global health initiativesVenice, Italy 22 June 2009 Why the world needs global health initiatives. Dr Margaret Chan, Director-General of the World Health Organization
http://www.who.int/dg/speeches/2009/global_health_initiatives_20090622/en/index.html

Malpractice Reform to Reduce Healthcare Costs

Michelle Mello and Troyen Brennan have an article in this week's New England Journal of Medicine outlining ways to enact health care tort reform. The premise, they argue, is that doctors too frequently practice defensive medicine because of fears of getting sued, resulting in excessive tests that they know are unlikely to be revealing and may even lead to harm. By changing the way courts punish liable doctors, the argument goes, substantial savings will accrue. Their rough calculation is that if even 1% of costs are reduced by changing physician practice, $22 billion will be trimmed from the health budget - not a trivial amount. From my personal experience, up to 5% of what doctors do is driven by fears of litigation. I can't tell you how many head CTs for chronic headaches I've ordered even though not a single one has ever been positive, nor is there any evidence to order such a test. It's the very small chance of a negative outcome weighted against the very large payouts that patients receive that drives decision making, pushing doctors to deviate from evidence-based decision making.

The obvious choice, to cap non-economic ("pain and suffering") damage awards, would apparently be very difficult to pass with a Democrat dominated legislature. Instead, the authors propose three more palatable compromise solutions:

• "Pre-emptive strike" - A.k.a disclosure-and-offer allows medical liability insurers to disclose mistakes and offer an up-front payment without taking the case to trial. This method does not prevent the patient from going to court, but preliminary data suggests that the vast majority accept the mediation and do not pursue the lengthy and costly court proceeding. Whether this approach actually reduces costs is still being researched.
• "Neutral panel" - One of the major drivers of high payouts is when a particularly gruesome or egregious violation generates huge damages from a sympathetic group of jurors. Another option is to create a special court with neutral doctors and medically trained judges who have a better sense of what was done right and wrong without the visceral driving force that some of these trials have.
• "Safe Harbor" - Doctors are often sued for following evidence-based practices but the patient had a bad outcome anyway. If a panel of neutral experts decides that the treatment was within an acceptable standard of care, the physician becomes immune from personal litigation.

Of these, I personally favor numbers two and three, and I can actually see both of them working together to reduce defensive medicine. In any case, I agree with the authors that some form of tort reform should be bundled with general health care reform as a means to reduce costs and promote value-based treatment.

Senate Passes Landmark Bill to Regulate Tobacco - NYTimes.com

Great news -
Senate Passes Landmark Bill to Regulate Tobacco - NYTimes.com: However this doesn't make sense "The Congressional Budget Office had estimated that the F.D.A. legislation would reduce youth smoking by 11 percent and adult smoking by 2 percent over the next decade beyond the declines that had already resulted from public education, higher taxes and smoke-free indoor space laws." How can a 11 percent reduction in children only result in a 2 percent decline in adults? Lag time doesn't seem to make sense. Great new regardless.

The AMA does not speak for all doctors.

A.M.A. Opposes Government-Sponsored Health Plan - NYTimes.com

This is infuriating. As the NYT correctly points out (unfortunately near the end of the article) - the AMA does not represent all physicians. Actually, there are 250k members, and last I checked I think there were approximately 730k physicians. Most physicians have more of an affinity to either their professional medical society (e.g. internal medicine is with American College of Physicians) or with their regional society (Massachusetts docs with Mass Med Society). The AMA does have the most members, but is by no means the voice of the majority of physicians.

Some thoughts from Bill on HC Reform

Bill Clinton Sees Hope for Health Care Changes, This Time - NYTimes.com

"To achieve universal coverage, instead of Mr. Clinton’s plan to require employers to provide it, Mr. Obama envisions creating a government-run health plan that would compete with private insurers.

Mr. Clinton said that as he looked at the matter in 1993 he believed that he had two options for providing universal coverage: either a tax increase or an employer mandate. Since he had already expended a lot of political capital on a deficit-reduction plan that included tax increases as well as spending cuts, he said he had to rely on the employer mandate.

“If you had an employer mandate, then you could leave the small businesses out or come up with enough revenues to subsidize the smaller employers — and since we couldn’t raise taxes, having an employer mandate guaranteed that the National Federation of Independent Businesses would join with the insurance companies,” he said. “Now they don’t have to have an employer mandate, because they can offer buy-ins. I hope they won’t give up on this public option.”