Sunday, October 28, 2007

Dave Durenberger Weighs In On Various and Sundry

Dave Durenberger publishes a regular commentary on health policy that is available via email subscription or download at: .

This week's commentary touches on a wide variety of important topics: health care policy (of course), medical device ethics, childrens hospitals and the medical arms race, the going rate for lobbyists (Dave is also an expert on this matter), and of all people, Clarence Thomas. Enjoy.

Selections from the 10.25.2007 Commentary:


For 35 increasingly knowledgeable years I’ve watched the medicalization of health and healthcare. There are rich financial rewards for medical specialization. The line between specialty medicine’s financial interest and its patient interest is blurred to the point of being unrecognizable. Hospital emergency rooms are expanding everywhere because psychiatric patient beds aren’t available for people who should have found a place in this “health system” long before the ER. And no one respects the growing need for or the economies associated with rewarding geriatric care.


Not many trained medical doctors signed the various constitutions in this country and the medical industry we have today didn’t exist. Today it does and we spend nearly a trillion dollars of tax revenue providing access to the service production of the medical industry for a majority – but not all Americans. Why?


The need for a national policy response rather than waiting out state by state coverage initiatives should be obvious. Dr. Ron Anderson, the CEO of Parkland Health and Hospital System in Dallas, reminded an audience of physician leaders at the University of St. Thomas last week that “over 43% of low income Texans are without insurance.” A respected Latino leader in MN believes 34% of our fast growing Latino population is without insurance coverage.


Dr. Barry Straub is the chief medical officer of CMS with responsibility for Medicare and Medicaid. He keynoted our Medical Arms Race Syndrome forum at the University of Minnesota last Sunday. Among his observations: “U.S. healthcare quality is inferior to that in other developed nations. It is a national disgrace that so much medical practice does not meet standard performance guidelines.


One of Minnesota’s best companies volunteered to take their Sprint Fidelis ICD leads off the market because of detected failures in the leads in some defibrillators.

Patients were advised if they wanted theirs replaced, to seek out a surgeon who does this and nothing but this for a living because it is a procedure requiring a great deal of skill to avoid adverse impact on the tissue of the vein around the implant. It was also obvious from the dialogue that companies like Medtronic went to the thinner and thinner leads like Fidelis to make it possible for more and more cardiac surgeons to perform the procedure.

What should I make of this? That the device design is driven by the potential for greater volume? or higher performance quality? That the patient public has a lot to learn about the practice of medicine and about the performance levels of individual physicians and surgeons. If we know what doctors know, and device manufacturers know, about quality performance we might demand more of everyone in this medical arms race and less from the FDA, CMS, and private insurers.


Five manufacturers of orthopedic devices agreed to end a Justice Department investigation into charges they created phony consulting arrangements with surgeons who do hip and knee replacements. The five will pay a total of $311 million to avoid larger financial penalties or criminal charges under anti-kickback statute....No mention of what penalties, if any, the many orthopedic surgeons will pay for accepting money they haven't earned.


People in need of implants don’t buy the implantable device. And do not pay for it. Device companies determine the market and a price which will maintain corporate pre-tax margins north of 50%. Surgeons decide what devices to use and hospitals buy and pay for them. Hospitals all belong to Group Purchasing Organizations which negotiate prices with manufacturers and make millions for the folks that run the GPOs. Then the device distributor takes a piece of the action and a certain number of surgeons in every profession involved make triple digit supplementary incomes for making the “buy and use” decision.

Nowhere in this process is patient assessment of performance quality an issue so how can we call them “prices” and why pay $100,000 a shot for national advertising.


We wondered aloud about the value to our Minnesota community in pediatric medical excellence and community costs of Fairview-University and Minnesota Children’s decision to raise nearly $500 million to improve and expand pediatric medical facilities rather than agreeing to a joint center of excellence. This after hearing that jilted UMN football suitor Denny Sanford had committed $400 million to renaming Sioux Valley Hospital in Sioux Falls, S.D. on condition they commit much of his gift to improving medical care for children in the area. It’s also being used to build a 3rd heart specialty center in Sioux Falls.

The attendant publicity may have dampened enthusiasm in the philanthropic community for two "modernization" plans. So Children’s Hospitals and Clinics of MN is asking the cities of Minneapolis and St. Paul to provide much of their expansion funding through public tax-exempt bonds. Unfortunately that doesn't exempt those of us who pay property taxes from contributing to the new buildings. Nor will we be exempt from paying part of it in the health insurance premiums we pay. And a third levy on us comes with the multi-million dollar tax exemption hospitals like this have from income, property, and transaction taxes.


Having had a brief fling as a lobbyist in my post-Senate career, I remember well the “going rate” for big-time access and influence. Like my friends Bob Dole and George Mitchell who partnered for a while. The 1995 rate was $35,000 a month and a minimum 12-month contract regardless of what you wanted your policy professional to do for you or how long it took. Today’s prices make our generation look like pikers. We read where it costs Turkey (or anyone else that wants a piece of a $71 million a year time-selling business) $1.2 million a year for former Louisiana Republican Congressman and almost-Speaker (after Newt) Bob Livingston. Bob can subcontract with former N.Y. Rep. Steve Solarz if he needs a big Dem. Retired Democratic House leader Dick Gephardt costs you the same $1.2 million.


Seeing someone you know in a lengthy (by 60' standards) television interview reveals the emotion that goes with deeply held convictions. Clarence Thomas really believes that the many efforts by a variety of Republican and Democratic lawmakers - from the civil war to the civil rights era - somehow cheapens all that he was able to accomplish on the trip from Pin Point, GA to Washington, D.C.

I was reminded that Justice Sandra Day O'Connor graduated, not at the middle of a Yale Law class, but no. 2 at Stanford Law. The best job offer she received was as a legal secretary in a gender-prejudiced legal world. Instead of doing the "15 cents sticker" on her degree, she has celebrated the civil rights achievement that people like she and the Supreme Court on which she was "honored" to serve have brought to all of us Americans.


"I'm looking forward to getting some things done for the American people...and if it doesn't get done, I'm looking forward to reminding the people as to why it's not getting done."

- President George W. Bush

The editors of the San Francisco Chronicle said of this:

"Sometimes it seems like the ultimate goal in Washington is not to accomplish anything, but to successfully blame the other party for a failure...OK, let's check the list [of policy problems]. The planet is heating up. The first Baby Boomers are qualifying for Social Security, a fiscal time bomb. The immigration system is broken. The health care system is falling apart. Millions of Americans are losing their homes to foreclosure. A war rages on. All of these issues are getting more rhetoric than resolution from each end of Pennsylvania Avenue."

Thanks, Dave, for some interesting commentary on a wide variety of topics.

Ciao, Bonzo