If you want to get a picture of the crazy quilt of US health care, take a look at the new Dartmouth Atlas Project report.

It shows that:

Medicare spending is rising more than twice as fast in Dallas as in San Diego.

Medicare is spending nearly three times more on seniors in Miami than in Honolulu.

In the image below, Wausau, Wisconsin is shown with rapidly rising Medicare costs amidst a sea of otherwise lower-spending Midwest hospital regions. Why?

Or you can go to this full interactive scroll-over-your-region map.

A news release accompanying the report says:

“This illustrates how huge inefficiencies in the U.S. health care system are hamstringing the nation’s ability to expand access to care.

The authors argue that the differences in growth are largely due to discretionary decisions by physicians that are influenced by the local availability of hospital beds, imaging centers and other resources—and a payment system that rewards growth and higher utilization.”

“To paraphrase a line from the gun control debate: technology doesn’t drive the growth in health care spending; people do,” said lead-author Dr. Elliott Fisher, principal investigator for the Dartmouth Atlas Project and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice. “The good news is that in many regions, spending is growing relatively slowly. Reformers can learn from these regions and put in place policies that help them sustain what they are doing now, and encourage high-cost, high-growth regions to change their ways.”

“This work demonstrates why health reformers should work to realign private and public payment schemes to benefit quality performance over the volume of services,” said Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation. “Clinicians who successfully provide high quality care and slow spending growth should be rewarded, not penalized.”

“This is an opportunity for physicians to lead,” said Dr. Julie Bynum, co-author and assistant professor of Medicine at Dartmouth Medical School. “But even though doctors still make most of the critical decisions about how and where their patients get care, they will need help from payers and policymakers. Physicians operate under the rules of a system that is rigged to reward high-cost care.”

More maps are available online.

So is the study, published in the New England Journal of Medicine.

There’s an important message for consumers here. This isn’t just academic policy wonk talk. Health care consumers need to know that there’s tremendous variation in the way health care is practiced in this country. There is tremendous uncertainty about best practices and best treatments. And – repeat after me –

MORE IS NOT ALWAYS BETTER – NEWER IS NOT ALWAYS BETTER – IN HEALTH CARE.

What if consumers could calculate the benefits and risks of taking a prescription drug as easily as they can gauge the carbs and calories of an Oreo cookie?

That’s the way Natasha Singer started her piece in the New York Times yesterday about a new proposal for improved benefits-and-harms disclosure on drug ads.

Dartmouth’s Steve Woloshin and Lisa Schwartz propose that the F.D.A. require new facts boxes on ads – somewhat akin to nutrition fact panels — “numerical tables that quantify the benefits of taking a drug compared with a placebo, and that list the odds of having side effects.”

Woloshin told the Times: “We thought, if you could do it for Cocoa Krispies or Diet Coke, why couldn’t you do it for Lunesta or other drugs?”

Other excerpt:

The Dartmouth researchers, in one example, used data from a published study of the insomnia drug Lunesta to create a benefit box showing that volunteers who took the sleeping pill nightly for six months typically fell asleep 15 minutes faster than people on a placebo. The table, e-mailed to a reporter, also indicates that volunteers taking Lunesta typically slept for six hours and 22 minutes — or only 37 minutes longer than the placebo group. There was no difference in life-threatening side effects among the groups.

In 2007, Sepracor, the maker of Lunesta, spent about $293 million on advertisements for the sleeping pill, the highest ad spending that year among drug brands, according to Nielsen.

The Medpedia Project has announced the public launch of the beta version of Medpedia.com, a health resource and technology platform for the worldwide health community. Harvard Medical School, Stanford School of Medicine, Berkeley School of Public Health, University of Michigan Medical School and other health organizations, are contributing in various ways to Medpedia. The goal of The Medpedia Project is to create a new model of how the world will assemble, maintain, critique and access medical knowledge. Since the announcement of The Medpedia Project in July 2008, over 110 organizations have contributed or pledged over 7,000 pages of content to the knowledge base, and thousands of people have become a part of the community.



For the general public, this page explains how to use Medpedia and this page list all the topics covered on medpedia.com.



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Ron Winslow has an important piece in the WSJ today based on this week’s JAMA study:

Tricoci P, Allen JM, Kramer JM, et al. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA 2009; 831-841.

Winslow’s lede:

Heart disease is among the most studied illnesses in all of medicine, yet just 11% of more than 2,700 recommendations approved by cardiologists for treating heart patients are supported by high-quality scientific testing, according to new research.

About half the medical recommendations for heart patients have limited scientific backing, according to (the study). Instead, they are based mostly on expert opinion — subjective viewpoints where consensus is often lacking.

Kudos to Jamie Hirsh and the Consumer Reports team on another terrific “reality check/ad watch” – this time on “stealth” ads for the stop-smoking drug Chantix.

CR has done several of these now, but they can’t do them fast enough in my view.

The truthtelling that should be done on direct-to-consumer drug ads is a huge task.

Remember: we’re one of only two countries on the globe that allows direct-to-consumer drug ads.
And New Zealand – the other – has been making noise about adopting a ban.

Which would leave us where we often are in health care: #1 atop the world!!!!

Just not in ways we should be proud of.

Someone stop me if you ever hear me say that I’ve seen the worst TV health news piece. The bottom keeps dropping.

This piece is a contender for bottom-dweller.

(Note: before you can actually enjoy the piece, you’ll have to watch a CBS promo in this clip for all the awards they’ve won. And you’ll see at the end their tagline, “Very Good News.” This piece, I warn you, will not win an award and was NOT very good news.)

Watch CBS Videos Online

Let’s recap:

A young woman whom the anchorman calls “healthy…gorgeous” but who wants to rid herself of a tiny fat pouch in her belly gets lunchtime liposuction. The surgeon comes on the set with her to chat with the anchorman. But in more than 5 minutes (an eternity in TV news!), they fail to discuss:

• evidence
• how widely the costs vary from the $3,000 the promoting-surgeon cited
• whether insurance pays for it.

Viewers should ask themselves: if this “healthy, gorgeous” young woman wanted to have a little fat pouch removed and if she were in your insurance pool and if insurance covered it, would you want your premiums to go up as a result?

Why don’t we have news stories about that?

That would be journalism. This was free advertising: 5 minutes worth!

So there’s money in the stimulus plan to create a process to compare treatments, tests and procedures – “comparative effectiveness” is the goal.

Of course the UK has had such an agency for a decade.

It has the nice-sounding acronym of NICE but many critics don’t think it’s so nice. It stands for the National Institute for Health and Clinical Excellence.

Matthew Holt had a good article about NICE last August.

And on the recent 10th anniversary of NICE, BMJ editor Fiona Godlee wrote about it an issue of the journal that contained a series of articles about NICE. She wrote:

Controversial from its inception and constantly in the public eye, NICE’s survival alone is surely something to celebrate. …

NICE is a national treasure. It needs critical friends. Perhaps beyond sheer survival the clearest signs of its achievement over the past 10 years are its undiminished unpopularity with the drug industry and its growing popularity with governments around the world. As Nigel Hawkes quips in his report on NICE’s global expansionism “the drug industry would love to have exported it, preferably somewhere like Mars.”

Maybe, finally, the US can adopt and refine some of the “comparative effectiveness” steps that the UK and other countries have been taking for years in the face of the medical arms race and out-of-control health care costs.

A college basketball player just gets out of the operating room and headlines across the country call the surgery a success!

I hope Dyson has a great recovery.

But such knee injuries have changed many hoopsters’ careers. Inane headlines like this promote the deification of surgeons and the “instant fix” image of surgery that can be so far from the truth.

I had ACL reconstruction surgery for a basketball injury in 1987. I’m still playing hoops weekly against undergrads. So I know the surgery can work. But I also remember how hard I worked at rehab. You can’t call it a success just because they sewed him up.

Remember the wise old warning: “The operation was a success but the patient died.”

If there’s any doubt about the impact of public relations efforts on news coverage of health products, look at what the PR company Fleishman-Hillard brags about on its website. They describe a campaign for a diarrhea vaccine. From their website:

Don’t Leave Home Without It

Fleishman-Hillard launches Dukoral. A three-pronged media relations campaign resulted in 19 million impressions (triple the project goal), physician acceptance and consumer demand for Dukoral.

Dukoral, the first and only oral vaccine for protection against most common causes of Traveller’s Diarrhea. For the project spokespeople were identified in key Canadian Markets (Vancouver, Toronto, Montreal-bilingual) willing to speak to the media about Dukoral. The spokespeople represented Dukoral to travel, healthcare and consumer media. All media coverage has had a direct impact on the target audiences. Media coverage incorporated key messages about Travellers’ Diarrhea and Dukoral’s role in the prevention of this potentially serious illness. Attributed to the extensive media coverage physician have reported to sales team that many patients have asked for Dukoral bringing in articles consumers themselves have read.

Journalists love toilet jokes in their stories. Melody Petersen, in her book, Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs, wrote that too many journalists too easily fall into drug company plans to create a market for a drug, such as, in one case, a drug for “overactive bladders.” “Dozens of journalists at newspapers and television stations across the country wrote stories about the disorder said to be destroying the lives of millions of Americans,” she wrote. “Editors and television news directors loved these reports. Silly stories of people running to the toilet brightened the day’s news.”

Dukoral is not yet approved by the FDA.

Thanks for the tip to Alan Cassels, who also points out questions about the vaccine’s effectiveness and its cost.

Former US Senator David Durenberger (R-Minn.), in his weekly e-mail newsletter, quotes George Halvorson, CEO of Kaiser-Permanente, the largest health maintenance (health and healthcare delivery and financing) company in the world.

“Expecting our massive, very well-financed, high revenue, high margin, high growth, healthcare infrastructure to voluntarily reduce costs and prices and expecting them to voluntarily and spontaneously improve either outcomes or care quality is unfortunately naive. It is almost entirely funded by a steady and massive stream of fees and cash payments that have no linkage to either care quality, efficiency or results. It is magical thinking to believe that health care delivery can, or even could, reform itself in any significant way. There is no economic reward for improving care.”