In the news:

A new study in the New England Journal of Medicine shows that the prescription drug benefit passed in 2003 (Medicare Part D) resulted in higher overall health care costs for most enrollees. However, it did lower costs for those who previously had limited coverage.

The study compared those who previously had no prescription drug coverage and those that had $150 and $350 quarterly caps on their private plans to those who had no cap on coverage, both before and after passage of the new benefit. From the study:

After 2 years of Part D, enrollees in the no-coverage group had increased their monthly drug spending by $41, as compared with that in the no-cap group, but that was roughly offset by a decrease of $33 in their monthly medical spending, perhaps because increased use of medication led to improved control of chronic illnesses. Similarly, the group with a previous $150 quarterly cap on drug spending increased their drug spending by $27, which was offset by a decrease of $46 in their medical spending. The group with a previous $350 quarterly cap spent $13 more on drugs and $30 more on other medical services.

President Obama's willingness to entertain an individual mandate and tax health benefits represents a shift from stances taken during the campaign, a Wall Street Journal story points out . . . . Pfizer's anti-smoking drug Chantix will get a black box warning after the Food and Drug Administration warned smokers of mental illness and suicidality side effects. GlaxoSmithKline's Zyban, which is also sold as Wellbutrin for depression, will get a similar warning, the New York Times reports . . . . Roche announces it will sell its anti-flu drug Tamiflu at about a one-third discount in the developing world. About 70 countries are eligible, excluding India which makes a generic version of the drug. . . . 

New York Times op-ed writer Rosanne Leipzig of the Mt. Sinai School of Medicine in New York offers a heartfelt plea for better geriatric medicine . . . . 

Do Third World countries have something to teach us about health care? This story in the Wall Street Journal looks at how an AIDS clinic in Alabama adopted lessons learned at one in Zambia to improve patient outcomes. It also features a low-cost technology for giving blood tests that is slightly less accurate than the standard test used in the U.S., which raises the important question of cost-effectiveness. Would the U.S. ever accept technologies that help more people at lower cost if the side effect is some people getting less than optimal care? "In the developing world, people are willing to make the tradeoff in accuracy for simplicity and low cost," the technology's developer tells the paper. "In the U.S., that kind of trade-off is a hard sell."

An Associated Press story in the Washington Post's online edition reports on a new study from the Trust for America's Health that shows obesity rates rose in 23 states last year and fell in none. . . . 

The Institute of Medicine today released its "top 100" list of priority comparative effectiveness research (CER) projects. The stimulus legislation called on the IOM to recommend how to spend $400 million given the secretary of the Health and Human Services department for CER under the stimulus act.

Here's a sleeper near the top of the list:

• Compare the effectiveness of dissemination and translation techniques to facilitate the use of CER by patients, clinicians, payers, and others.

Given that Congress will probably insert language in health care reform legislation stipulating no one should ever be bound to actually use the findings of comparative effectiveness research (why that's like EVIL BIG GOVERNMENT coming between YOU and YOUR DOCTOR), it's probably a good idea for someone to study how to "disseminate and translate" this information so that parts of the health care system might actually put it to use.

Okay, now that I have that off my chest, here's some of the more interesting proposals near the top of the IOM list:

• Compare the effectiveness of management strategies for localized prostate cancer (e.g., active surveillance, radical prostatectomy [conventional, robotic, and laparoscopic], and radiotherapy [conformal, brachytherapy, proton-beam, and intensity-modulated radiotherapy]) on survival, recurrence, side effects, quality of life, and costs.
• Establish a prospective registry to compare the effectiveness of treatment strategies for low back pain without neurological deficit or spinal deformity.
• Compare the effectiveness of school-based interventions involving meal programs, vending machines, and physical education, at different levels of intensity, in preventing and treating overweight and obesity in children and adolescents.
• Compare the effectiveness of imaging technologies in diagnosing, staging, and monitoring patients with cancer including positron emission tomography (PET), magnetic resonance imaging (MRI), and computed tomography (CT).

And near the bottom?

• Compare the effectiveness of different treatment strategies (e.g., psychotherapy, antidepressants, combination treatment with case management) for depression after myocardial infarction on medication adherence, cardiovascular events, hospitalization, and death.
• Compare the effectiveness of different long-term treatments for acne.

Three cheers for Dr. Harold Sox and the committee. They weren't afraid to elevate some of the toughest issues in medicine -- the ones where entrenched special interests earn lots of money practicing lack-of-evidence-based medicine and oppose efforts to know what works best. It remains to be seen if HHS Secretary Kathleen Sebelius and whomever the president chooses to run the Center for Medicare and Medicaid Services adheres to this well-thought-out priority list.

Headline of the day:

Bernie Madoff gets 150 years for running a Ponzi scheme that wiped out the life savings of his "investors." Does that mean that the investment bankers, hedge funds operators and insurance company executives whose subprime and derivative shenanigans turned everyone's 401-k into a 201-k will get 75 years?

And in the news:

The New York Times' top health care-related story today dresses up a rehash of gubernatorial concerns about putting more burdens on Medicaid by suggesting it is an effort by President Obama to move the health care debate out of Washington. . . . Kaiser Health News teams up with the Washington Post to explore a major contributor to rising health care costs -- avoidable hospitals readmissions, usually among the elderly chronically ill. "Their exerpiences of being readmitted time and again reflect many of the deficiencies in a fragmented, poorly conordinated health system geared toward acute care," Joanne Kenen writes. . . .

A subcommittee chaired by Sen. Arlen Specter (D-PA) traveled to Philadelphia to hear oncologist Gary Kao, who practiced at the local Veterans Administration hospital, defend his use of implanted radiation seeds to treat prostate cancer. A Times investigation claimed a high proportion of his operations had been botched. . . . Withdrawal symptoms associated with benzodiazepine use for anxiety draws attention from this Post article. . . .

The Economist magazine examines America's health care woes in a series of articles and concludes in this editorial that the two most important reforms for bending the cost curve down are eliminating the tax deduction for health care benefits and putting every doctor on a salary like they do at the Mayo Clinic and Kaiser Permanente. "Reform must aim to encourage more use of managed health care, provided by doctors who are salaried, or paid by results rather than for every catheter they insert," it concludes. . . .

Cancer drugs that prolong life two months or less should only be studied by National Institute of Health researchers if they cost less than $20,000 per course of treatment, two NIH scientists editorialize in the latest Journal of the National Cancer Institute (subscription required). Medpage Today summarized the article. The Wall Street Journal, which frequently editorializes in favor of unlimited access to unproven cancer therapies, buries a good overview story on the high cost of cancer drugs on page D4. . . .

Johnson & Johnson won a $1.67 billion patent infringement case against Abbott Labs, the Wall Street Journal reports. The case involved rival biologic treatments, Remicade and Humira, that target tumor necrosis factor to treat  rheumatoid arthritis. . . .

Emory University psychologist and political consultant Drew Westen in the weekend Washington Post offers a troubling view of the public's role in health care reform. While reform's reality involves complicated technical issues like insurance exchanges, public plan governance, physician and hospital payments and who will pay higher taxes, the public's understanding of these issues is virtually non-existent, Westen assumes.

Instead, public knowledge comes from a media environment where Republican consultants craft messages about a government takeover of health care and Democratic consultants (the author among them) promise a family doctor for everyone. Never mind that neither message even remotely resembles reality.

Nowhere in the article does Westen pay homage to the democratic ideal that an informed electorate has a role to play in policy debates like health care reform. Nor does he lament the passing of an informed electorate. Such statements used to be a staple in discussions about political messaging and the impact it was having on policy debates.

It hasn't always been thus. I've been reading "Lords of Finance: The Bankers Who Broke the World" by Liaquat Ahamed, a former investment banker who spent the past ten years researching the errors made in the late 1920s and early 1930s that led to the Great Depression. Near the end of the book, he recounts how President Roosevelt explained the bank holiday declared immediately after he took office. His first fireside chat carefully detailed for average Americans the complicated workings of banks that had forced his hand. The next day, folk humorist Will Rogers marveled at the speech's clarity. In a letter to the New York Times, he wrote: "Our president took such a dry subject as banking . . . (and) made everybody understand it, even the bankers."

Today, few media outlets even bother to explain the intricacies of policy choices. Politicians, the special interests and the communications experts who craft their messages can safety assume the public will have a poor grasp on reality. Marshall McLuhan has been turned on his head. The message is now the medium.