The economics of organ vending

The lede:

Nearly 100,000 Americans are waiting for an organ transplant. Every day, the wait for 17 of those people ends in death.

It is a wait that could be drastically shortened or even eliminated if a market for live and cadaveric organs were allowed to operate, according to a paper co-authored by Nobel Prize-winning economist Gary S. Becker, PhD, and published last year in the Journal of Economic Perspectives.

The study comes on the heels of what observers say is slow but steady progress in breaking down opposition to testing the idea of financial incentives in an effort to combat an organ shortage growing by 5% each year. But resistance among many in the transplant community is still fierce, as other efforts such as paired donation exchanges begin to take off.

The whole shebang.

Refusing to serve

The lede:

A recent American College of Obstetricians and Gynecologists’ position statement outlining the limits of conscientious refusal in reproductive medicine is drawing fire from physicians who oppose abortion.

The ACOG Committee on Ethics opinion says doctors whose personal beliefs may require them to “deviate from standard practices” such as providing abortion, sterilization or contraceptives should:

  • Give patients prior notice of their moral commitments and provide accurate and unbiased information about reproductive services.
  • Refer patients in a timely manner to another doctor who can provide the requested service.
  • Provide medically indicated services in an emergency when referral is impossible or might affect a patient’s physical or emotional health.
  • Practice close to physicians who will provide legal services or ensure that referral processes are in place so that patient access is not impeded.

The opinion, published in November 2007, comes in response to heated debate over some pharmacists’ refusal to fill patient prescriptions for Plan B, known as the morning-after pill. The Food and Drug Administration in September 2006 approved Plan B for over-the-counter status, but the debate over the right to refuse certain procedures or medication has not disappeared.

The whole shebang.

Rooting interests

The only way for a libertarian who is also a political junkie to get through a presidential campaign is to develop some kind of rooting interest. This usually involves rooting against the most odious person in the race.

The libertarian side of me is constantly making mental calculations about the leading presidential contenders and how their election might affect the perennial struggle between individual liberty and government power. Picking between the Democrat and the Republican on this basis is sort of like trying to choose between a turtle and a snail about who will add the most to your track team. Both will be terribly lousy, so it’s just a matter of degree.

With only minimal policy differences to differentiate the contenders, my political junkie side, the human side, develops very superficial opinions about who I simply won’t be able to stomach watching on my TV for at least the next four years.

Since becoming a libertarian in 1994, these interests have usually coincided. It was easy to root for Dole against Clinton in 1996, as Dole had both the policy and personality advantages going for him.

You’ll recall that Dole, while always a moderate, was proposing major tax reform and was set to work with a GOP Congress which at that point had not completely sold out its limited-government ideals. In fact, they’d just shut down the government in a bruising budget battle with Clinton. Dole’s wicked sense of humor, curmudgeonly personality and constant references to himself in the third person made him easy to like on a personal level.

He certainly was not as smarmy, self-satisfied, duplicitous and odious as Bill Clinton, who was fresh from likening those who blew up the Oklahoma City federal building to Republicans who favored slowing the growth of spending on Medicare. He also had passed an entirely symbolic semiautomatic gun ban, raised taxes, and attempted to have the government “manage competition” in the health insurance industry. By election time, he was running on supporting school uniforms.

In 2000, it was a very tough call. Bush was clearly running away from the ideas of free markets and smaller government, while Gore was running on obnoxious “people vs. the powerful” theme. He was a liberal technocrat’s wet dream, and on the personal level I still held against him his despicable 1996 Democratic convention speech where he used his sister’s lung-cancer death to score political points. His obnoxious debate performances only confirmed how insufferable he would be to have as president for four years.

Bush, with his frequent malapropisms, would make excellent fodder for the late-night comics, I thought. So I gave him the very, very slight edge.

By 2004, Bush had already established himself as one of the worst presidents in U.S. history for self-evident reasons. His awfulness on policy filled me with so much rage that I could hardly generate a chuckle at his occasionally stupid and embarrassing remarks.

Kerry was no prize on personality, and you’ll recall that on the war he argued not that it should be ended but that he could fight it better. I suspected, though, that he would be much more likely to pull out were he elected. And indeed, he’s since come to favor withdrawing from Iraq. More than anything, I hoped a Kerry victory would be seen as a rebuke of the idea of pre-emptive war. In the time since, the course of the war itself has become such a rebuke.

And how about now? Normally, I’d be rooting for a Republican under the assumption that the Democrats will retain Congress and it’s best to aim for divided government and gridlock. But it seems likely the GOP nominee will remain committed to a forever war in Iraq and that the Democrats won’t be able to get a veto-proof majority to stop it. And the war is sort of a binary issue, and one the president will determine. So that means I’ve to root for a Democrat.

Also, I think George Will is right to note that it is almost certain that a Democrat will win the presidency this year:

Today, all the usual indicators are dismal for Republicans. If that broad assertion seems counterintuitive, produce a counterexample. The adverse indicators include: shifts in voters’ identifications with the two parties (Democrats now 50 percent, Republicans 36 percent); the tendency of independents (they favored Democratic candidates by 18 points in 2006); the fact that Democrats hold a majority of congressional seats in states with 303 electoral votes; the Democrats’ strength and the Republicans’ relative weakness in fundraising; the percentage of Americans who think the country is on the “wrong track”; the Republicans’ enthusiasm deficit relative to Democrats’ embrace of Hillary Clinton and Barack Obama, one of whom will be nominated.

So which one should I root for? Which one should libertarians root for?

First, the policy argument. Barack Obama was right on the war, and I believe he is more likely to follow through with his promise to end it. While Obama’s far from a noninterventionist, he is not the hawk that Hillary’s proven herself to be over time (remember the Kosovo war she got Bill to start as a price for standing by him after the Lewinsky fiasco?).

Both Hillary and Obama are terribly liberal, and both want to dramatically increase government control of health care. But I think that tactically, Hillary may be far preferable on policy. Obama — a magnetic, likeable and fresh face — could very will win a sweeping victory that goes all the way down the ticket, giving Democrats a much larger margin in Congress.

The Republicans are clearly flummoxed about how they could attack him. Their only hope would be a major foreign-policy crisis that they could use to highlight his allegedly slim resume (which is relative, I say; he has more foreign-policy experience than most governors or mayors).

Hillary, on the other hand, is deeply hated by Republicans and not much liked by independents. The trends would still carry her to victory, but it would be a much smaller victory. And once in office, I believe it would be much harder for her to marshal support for the many, many, many grandiose schemes she has in mind. Her mandate will be minimal, compared to the 55% or even better popular vote I think Obama could easily win.

Then again, I cannot stand the woman. Her voice irritates me. Her disdainful attitude toward those who disagree with her is disgusting. She literally cries, “Woe is me.” She shares all of her husband’s flaws and none of his charm. Once she is endowed with the terrible and expansive powers of the modern presidency (for which she’s expressed an alarming fondness), I’m quite sure my hatred for her will grow even stronger.

But, given the likely and frightening alternative of a popular, effective liberal president such as Obama, I guess this grinch may be rooting for Hillary after all.

(Also posted to Sinners in the Hands of Angry Blog.)

Paying dearly for mistakes

The lede:

The movement to align patient safety and payment seems to be picking up a full head of steam. Hospitals and payers are coalescing around the idea that no one should get paid for so-called never events — serious reportable events, such as wrong-site surgery, that kill or maim patients.

Perhaps most significantly, the BlueCross BlueShield Assn. announced in November 2007 that its plans will work toward ending payment for never events. The change will be phased in over several years as the Blues alters its coding and claims processes. A spokesman said adoption will vary among the 39 Blues plans, which insure more than 100 million people, because the change requires renegotiating contracts and securing agreements from local physicians and hospitals.

The whole shebang.

Radiant with cancer worries

The lede:

A recent study estimates that between 1.5% and 2% of all cancers can be attributed to radiation from the 62 million computed tomography scans Americans get each year. The finding comes on the heels of earlier, similar risk estimates, and it has some experts saying physicians should think twice about ordering the test.

The review article in the Nov. 29, 2007, New England Journal of Medicine arrives at its estimate by examining the cancer effects on the 25,000 Japanese who survived the 1945 atomic bombs and received radiation doses equivalent to the x-rays emitted by several CT scans.

The authors, David J. Brenner, PhD, and Eric J. Hall, PhD, are professors at the Columbia University Center for Radiological Research and have studied the cancer-causing effects of imaging for years. They write that the evidence of cancer risk from CTs is “reasonably convincing” for adults and “very convincing for children.”

The whole shebang.

Ethical ideals versus reality

The lede:

Doctors agree on the basic tenets of medical professionalism, but they frequently fail to live up to those ideals in practice, according to a survey of more than 1,600 physicians in the Dec. 4 Annals of Internal Medicine.

Nearly all of the physicians surveyed agreed doctors should use medical resources appropriately, tell patients the truth, minimize disparities, see patients regardless of their ability to pay, maintain board certifications, evaluate peers’ care, avoid sex with patients, work on quality initiatives, disclose conflicts of interest, report impaired or incompetent physicians, and report medical errors.

But more than half of doctors told investigators that they failed to report a serious medical error they observed, or a colleague who was impaired or incompetent, to authorities in the last three years. And more than a third of the doctors said they would order an unnecessary magnetic resonance imaging scan to mollify an insistent patient.

The whole shebang.

Medical ethics during the war on terror

The lede:

Medical students get a failing grade on their knowledge of physicians’ ethical obligations during wartime, according to a new study authored by a team of Harvard Medical School physicians.

The authors said their study, published in October in the International Journal of Health Services, should prompt medical schools to educate future doctors more thoroughly on the ethical questions they could face in an age of terror and torture.

But experts said that although medical curricula could cover military medical ethics, such instruction should be folded into discussions about the broader problem of dual loyalty — when doctors’ advocacy for the patient conflicts with other institutional or societal objectives.

The whole shebang.

Saying no to embryos?

The lede:

Two teams of scientists simultaneously announced they have reprogrammed human skin cells to obtain pluripotency, the characteristic hailed in embryonic stem cells as having the potential for therapeutic breakthroughs in areas ranging from Parkinson’s disease to diabetes.

Scientists in Japan and Wisconsin created the so-called induced pluripotent cells by introducing different combinations of genes into skin cells that are normally switched off after embryonic cells differentiate into various cell types. The results were published last month in Cell and Nature, respectively.

Researchers, ethicists, religious leaders and politicians hailed the findings, saying the innovative work could allow society to reap scientific and medical benefits of stem cell research without destroying embryos.

The whole shebang.

Size matters

The lede:

Large physician groups have long had a head start on solo and small practices in the medical marketplace because they can negotiate better health plan contracts. Now, a rising tide of evidence indicates that size also confers a quality advantage.

Researchers admit that the medical literature emerging on the relationship between group size and quality is far from a slam dunk. They argue, however, that bigger physician groups can pool capital to pay for electronic medical records systems and other quality initiatives that help them more reliably deliver guideline-based care.

On the opposite end of the spectrum, a small but growing movement of doctors is experimenting with a leaner model of medicine that they say improves the financial viability of solo and small-group practice and, most importantly, improves patient care.

The whole shebang.

Redesigning informed consent

The lede:

Toni Cordell’s surgery would be “an easy repair,” her doctor said. Embarrassed at being a slow reader, she signed the informed-consent papers she was given without understanding them.

She said no one, including her doctor, explained the procedure in detail beforehand or uttered the word “hysterectomy.” Cordell didn’t discover the nature of her operation until months after surgery when an office nurse inquired about her recovery.

Cordell’s story of being bewildered by medical-legal jargon is not unique. According to a 2005 National Quality Forum report, between 60% and 70% of patients do not read or understand informed-consent documents and nearly half cannot recall the exact nature of the operation to be performed.

Now a growing number of hospitals and physicians are moving to redesign informed-consent protocols. They are using new computer technology and education techniques to improve safety and ensure that patients understand a surgery’s risks and benefits. Informed consent is a process, they say, not a piece of paper.

The whole shebang.

Regulating drug industry gifts to physicians

The lede:

Thirteen states this year have seen legislative proposals aimed at limiting financial relationships between physicians and drugmakers. Most bills failed to pass, due to heavy pressure from pharmaceutical lobbyists, experts said, but new efforts are afoot.

The latest proposals include a Michigan bill that would make that state the second in the nation after Minnesota to place a limit — $100 — on the total value of gifts a drugmaker can give a physician in a year. Michigan and Massachusetts are considering so-called sunshine laws requiring drug companies to publicly disclose any gifts, payments, subsidies or incentives worth more than $25.

The whole shebang.

Who’s a good doctor?

The lede:

The Robert Wood Johnson Foundation is pouring $15.9 million into a new effort to give doctors and the public a more accurate assessment of physician performance.

The plan is to combine national Medicare and private health plan claims data and then use the data for public reporting of physician performance on quality and cost measures. Reporting in select areas is set for 2010.

The initiative comes on top of criticism that the nation’s dozens of quality measurement and reporting efforts are redundant or rely on widely varying metrics. For example, a 2005 Institute of Medicine report on performance measurement called for a new office in Health and Human Services to coordinate and fund the development of metrics for pay-for-performance and public reporting programs.

The whole shebang.

Doctors and executions

My stories for American Medical News are now freely available for about 90 days after they go live on the Web site. So, I’ve decided to start posting the first few grafs and links to the stories here in case you’re interested in reading.

The beat — medical ethics, patient safety and health care quality — is pretty interesting because quite a few of the stories are of great interest to many people who are not physicians. A great example is this story.

The lede:

The only state medical board in the country with policy declaring physician participation in executions “a departure from the ethics of the medical profession” and grounds for discipline was rebuked in state court late last month.

Wake County (N.C.) Superior Court Judge Donald W. Stephens ruled that the North Carolina Medical Board overstepped its authority in threatening to punish doctors who take an active role in the death chamber. But executions in the state will not resume due to the pending cases of five North Carolina death-row inmates on lethal injection protocols.

Read the whole shebang.