Friday, July 31, 2009

Please Cut the Crap!: Deconstructing the Right Wing Lies on the Health Insurance Bill#more#more

Please Cut the Crap!: Deconstructing the Right Wing Lies on the Health Insurance Bill#more#more:

The right's lies about the current health insurance proposals before Congress have rarely been compiled in such concise form before.

What follows is an article from the Right Wing blog ChronWatch:

Page After Page of Reasons to Hate ObamaCare
By Alan Caruba

The problem is, there's something missing, such as context. See, the writer is expecting the reader to take everything as gospel, and agree that it's bad, without any sort of explanation. It's a list of all of the things that are wrong with the current state of the health care reform bill before Congress. If you'd like to follow along, feel free to click here to go to the bill itself. In fact, I would encourage you to look at it for yourself; it's an easy way to learn what's actually in it, without having to read through all of the legalese.

We're not called Please Cut the Crap for no reason. Below each item the right wing assures readers we're supposed to hate, I've inserted context, and explained why you really shouldn't hate it. Unless you should. All of my responses are italicized and printed in red, so that you can tell whose words are whose.

I'll warn you, this is a long one, but it's an important one, so get a glass of tea, print this out, and read it to everyone who spews one of these talking points, because this really does touch on pretty much all of the right's talking points. And now you'll be able to refute them. Isn't that cool?"

Follow the link to read it all.

A friend sent me this email from a right wing relative, and it was just too full of crap to spend the time debunking, but fortunately the good people at "Please Cut the Crap" did it for me!

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Doctor Self-Referrals Part of Health-Care Cost Trend -

Doctor Self-Referrals Part of Health-Care Cost Trend -

"In August 2005, doctors at Urological Associates, a medical practice on the Iowa-Illinois border, ordered nine CT scans for patients covered by Wellmark Blue Cross and Blue Shield insurance. In September that year, they ordered eight. But then the numbers rose steeply. The urologists ordered 35 scans in October, 41 in November and 55 in December. Within seven months, they were ordering scans at a rate that had climbed more than 700 percent.

"The increase came in the months after the urologists bought their own CT scanner, according to documents obtained by The Washington Post. Instead of referring patients to radiologists, the doctors started conducting their own imaging -- and drawing insurance reimbursements for each of those patients."

It is clear some oxen have to be gored, or at least hobbled, to "bend the curve." Let's start being explicit about where to do this. Private insurers, over-utilizing physicians, drug and equipment manufacturers and suppliers. Let's start the hard discussions, please.

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Thursday, July 30, 2009

What the Mayo Clinic knows | | Detroit Free Press

What the Mayo Clinic knows Detroit Free Press:

Three goals underscore our nation's ongoing healthcare reform debate: 1) insurance for the uninsured, 2) improved quality, and 3) reduced cost. Mayo Clinic serves as a model for higher quality healthcare at a lower cost.

President Barack Obama, after referencing Mayo Clinic and Cleveland Clinic, advised: 'We should learn from their successes and promote the best practices, not the most expensive ones.' Atul Gawande writes in the New Yorker, 'Rochester, Minn., where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest 15% of the country -- $6,688 per enrollee in 2006.

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Wednesday, July 29, 2009

Rationing? Say it ain't so!

Blue Cross praised employees who dropped sick policyholders, lawmaker says - Los Angeles Times:

But documents obtained by the House Committee on Energy and Commerce and released today show that the company's employee performance evaluation program did include a review of rescission activity.

The documents show, for instance, that one Blue Cross employee earned a perfect score of '5' for 'exceptional performance' on an evaluation that noted the employee's role in dropping thousands of policyholders and avoiding nearly $10 million worth of medical care.

WellPoint's Blue Cross of California subsidiary and two other insurers saved more than $300 million in medical claims by canceling more than 20,000 sick policyholders over a five-year period, the House committee said.

'When times are good, the insurance company is happy to sign you up and take your money in the form of premiums,' Stupak said. 'But when times are bad, and you are afflicted with cancer or some other life-threatening disease, it is supposed to honor its commitments and stand by you in your time of need.

'Instead, some insurance companies use a technicality to justify breaking its promise, at a time when most patients are too weak to fight back,' he said.

Lawmakers -- Republicans and Democrats alike -- decried the practice of canceling policies of ill policyholders and grilled insurance executives about it.

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Doctors Oppose Giving Commission Power Over Medicare Payments -

Doctors Oppose Giving Commission Power Over Medicare Payments -

But doctors are objecting to proposals that would allow a federal commission to set the size of Medicare payments to doctors, hospitals and other health-care providers. Under a proposal from White House budget director Peter Orszag, if the president accepted the commission's recommendations, they would automatically take effect unless Congress acted to block them.
Doctors' objections to the commission idea highlight the difficulty of maintaining the support of different health-care constituencies when the focus turns to controlling costs.
Surgeons would 'vigorously oppose' legislation that gave an unelected executive agency power to set Medicare rates, said the American College of Surgeons, which claims more than 74,000 members, in a letter to House Speaker Nancy Pelosi last week. Several surgical-specialty societies also signed the letter.
The AMA, which claims 250,000 members, said a commission shouldn't be authorized to set Medicare payment rates for physicians. 'If the solution is we're just going to have a big board that will make draconian slashes, that's not getting at the root cause of what the problem is,' said AMA President J. James Rohack.

This is interesting. First, reimbursements are virtually set now by an unelected board, the RUC, made up largely of the highly paid, procedure based specialists.

Second, I just heard Chuck Grassley on NPR this morning saying the House and Kennedy Bills did nothing to bend the curve. This is what is required to bend the curve. Put up or shut up. Bending the curve isn't some magical thing where everyone gets to keep making as much money, on the same trajectory as they do now.

And it's worth pushing back on the AMA in particular. They've been talking a good game about what needs to be done to improve health care, reluctantly (because of fear of retribution, I suspect) pointing out whose oxen to gore, but they've been very silent about what physicians will be required to give up in all of this.

I frankly don't expect to have to give up much, (I'm 49) and what I do give up will occur over ten to twenty years and so accommodation will be made by the "youngsters," those going into and coming out of medical school and residencies now). They are the the physicians who will actually be affected by this. The old guys pissing and moaning are ready to retire soon, so shouldn't be holding the country hostage to their reactionary, out dated ideas of what medicine should be about.

UPDATE: I was researching Medcare for a talk on the 44th anniversary of the program, and it is worth mentioning that one of the things LBJ had to do to pass Medicare was to cave to the American Medical Association and American Hospital Association, essentially giving them whatever was required to stop opposing the legislation. This had good and bad effects: lots of hospital construction, advances in medicine, and huge revenue boosts for hospitals and doctors.

On principle, we should not cave to get reform, but on a pragmatic level, fear works and the erosion in support for reform is evidence of that. But let's call BS, at least, on Grassley and the other reborn deficit hawks: If you want to bend the curve, then you have to make some tough choices.

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Wednesday, July 15, 2009

Health Affairs - 2 articles on the cost of private insurers to the system

Two articles from Health Affairs regarding the cost of Private Health Insurers, for profit and not for profit, to physicians' practices, bottom lines, time and aggravation.

Peering Into The Black Box: Billing And Insurance Activities In A Medical Group -- Sakowski et al. 28 (4): w544 -- Health Affairs:

"Billing and insurance–related functions have been reported to consume 14 percent of medical group revenue, but little is known about the costs associated with performing specific activities. We conducted semistructured interviews, observed work flows, analyzed department budgets, and surveyed clinicians to evaluate these activities at a large multispecialty medical group. We identified 0.67 nonclinical full-time-equivalent (FTE) staff working on billing and insurance functions per FTE physician. In addition, clinicians spent more than thirty-five minutes per day performing these tasks. The cost to medical groups, including clinicians’ time, was at least $85,276 per FTE physician (10 percent of revenue)."

What Does It Cost Physician Practices To Interact With Health Insurance Plans? -- Casalino et al. 28 (4): w533 -- Health Affairs: "Physicians have long expressed dissatisfaction with the time they and their staffs spend interacting with health plans. However, little information exists about the extent of these interactions. We conducted a national survey on this subject of physicians and practice administrators. Physicians reported spending three hours weekly interacting with plans; nursing and clerical staff spent much larger amounts of time. When time is converted to dollars, we estimate that the national time cost to practices of interactions with plans is at least $23 billion to $31 billion each year."

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Monday, July 13, 2009

Medicare's 'No' on Virtual Colonoscopy Stirs Expert Debate -

Medicare's 'No' on Virtual Colonoscopy Stirs Expert Debate -

Just a marker for when the topic comes up. basically Medicare, for the first time, has indicated that the evidence for virtual colonoscopy is not yet adequate to warrant reimbursement at this time. This will be reconsidered if new evidence accumulates.

It's worth saying that this is how medicine should work, but it has become a favorite
piece of evidence for Sen. Tom Coburn that the world of American Medical Paradise is coming to a totalitarian halt.

Researchers do studies to evaluate treatments, medications, etc., and when a significant amount of evidence accumulates, the treatment enters general use.

Sad part is, this works exceptionally well when procedures are involved because of the fee basis for physician reimbursement and the lopsided reimbursement that hospitals and surgery centers receive for procedures.

It doesn't work so well getting new methods of medically managing patients out into standard practice. This is what Comparative Effectiveness Research should help. Finding out wht works and what doesn't and developing new standards and ways for physicians to implement them to the bedside or office.

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Sunday, July 12, 2009

What do other countries do? - Kansas City Star

What do other countries do? - Kansas City Star:

"In Britain, famously, they wait.

"To replace a hip, for instance, means months before surgery.

"Spaniards and Italians have single-payer health care systems, but they leave it to the cities and villages, not the capitals, to run things. The Greeks demand all medical bills be covered by universal insurance, but let doctors hit up patients for more.

"The Swiss are required to buy health insurance, and virtually all do.
Health care systems around the world vary like cuisine, reflecting customs and history. Some ingredients travel better than others."

Bravo to writer Scott Canon of the KC Star for doing a piece on international health care systems.

I quibble with some of it, particularly the first line, and wrote Canon about it:

Thanks, Mr. Canon for your piece "A Universal Pain", which appeared in my Pittsburgh Post-Gazette today. This kind of reporting is in very short supply and should be front and center in our ongoing discussions on health care, not relegated to the disparaging remarks hurled at Canada by conservatives.

But, I am curious about where you got some of your information. Some seems more up to date than mine, and some less so.

The most glaring one is in the first paragraph regarding waiting times in the UK. Here is more recent news:

Further, there are countries with universal health care unlike us, but without significant waiting times, and with better quality outcomes than our own (and I know you praised Germany's system, which is my favorite model):

A final point, although health care is pushing budgets to the brink internationally, it is very important to remind the public that increasing expenditure from 8 or 9 or 10% of GDP by one or two percent, compared to our 17 or 18 or 19% in our system is a big difference.

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Do we do better in the US on prostate cancer?

Four Pinocchios for Recidivist Rudy - Fact Checker:

This is not about Rudy Giuliani, he's irreleveant, but this is about the mythology that remains in the World of Fox about poor outcomes elsewhere. Somebody brought this one up recently (prostate Ca) so I put this here for future reference.

"Let's begin by deconstructing the original Giuliani claim, featured in a campaign ad in New Hampshire. It rests on a crude statistical calculation by his medical adviser, David Gratzer, on the basis of a 2000 study by a pair of health experts from Johns Hopkins university. According to Gratzer, '49 Britons per 100,000 were diagnosed with prostate cancer, and 28 per 100,000 died of it. This means that 57 percent of Britons diagnosed with prostate cancer died of it; and consequently, that just 43 percent survived.'

There are several problems with this line of reasoning, according to health experts.

In order to make statistically valid comparisons in epidemiology, it is necessary to track the same population. Because prostate cancer is a slow-developing tumor, it is probable that the Britons who died of prostate cancer in 2000 contracted the disease 15 years earlier. They represent an entirely different cohort of cancer sufferers than those who were diagnosed with the disease in 2000. The number of Britons diagnosed with the disease is itself a subset of the number of Britons with the disease.

'You would get an F in epidemiology at Johns Hopkins if you did that calculation,' said Johns Hopkins professor Gerard Anderson, whose 2000 study 'Multinational Comparisons of Health Systems Data' has been cited by Gratzer as a source for his statistics. 'Numerators and denominators have to be the same population.'

Five-year prostate cancer survival rates are higher in the United States than in Britain but, according to Howard Parnes of the National Cancer Institute, this is largely a statistical illusion. Americans are screened for the disease earlier and more systematically than Britons. If you are detected with prostate cancer symptoms at age 58 in year one of a disease that takes fifteen years to kill you, your chances of surviving another five years (until the age of 63) are obviously much higher than if your cancer is detected in year eleven, at the age of 68. Both Anderson and Parnes say that it is impossible, on the basis of the available data, to conclude that Americans have a significantly better chance of surviving prostate cancer than Britons.

Whether or not early screening actually reduces mortality from prostate cancer is the subject of much controversy among researchers, both in the United States and Europe. According to Otis Brawley, chief medical officer for the American Cancer Society, "at least 50 percent of men diagnosed with prostate cancer don't need to be treated. The problem is that we can't figure out which men need treatment, and which don't."

In an attempt to figure out if screening for prostate cancer does indeed save lives, the National Cancer Institute has been following 70,000 men since 1992, but has yet to a firm conclusion, Brawley said. Half of the men in the sample are being screened and the other half are not being screened. An August 2007 NCI report said it was still unclear whether "earlier detection and consequent earlier treatment" led to "any change in the natural history and outcome of the disease." Screening can lead to "over-treatment" which can in turn result in undesirable side effects such as erectile dysfunction and incontinence.

"This is getting completely ridiculous," e-mailed Giuliani spokesman Jason Miller. "You are still not getting it. The point the mayor has made is that privatized medicine is better than socialized medicine. If you can find one person who said they'd rather be treated for prostate cancer in the UK instead of the US, we'd like to meet them."

UPDATE WEDNESDAY 4:30 P.M.: Reader Jim Crowder asked an interesting question this morning, in response to Dr. Brawley's statement that at least 50 per cent of men diagnosed with prostate cancer "don't need to be treated." Crowder asked, "OK, If I am in the 1/2 group that would benefit by earlier treatment, wouldn't I rather be in the US and receive it? In fact I have received treatment."

I [Fact Checker] asked Dr Brawley to respond. Here is what he says:

We know that at least half of the screened and detected do not need treatment and any treatment they get can only give them side effects of treatment, including a 0.5% to 1% chance of death from treatment.We do not know that we benefit the other half who have a disease that is destined to disrupt their life by causing symptoms and in many death. Indeed some of our clinical treatment studies are designed to figure out whether we cure those who need to be cured.

Connecticut versus Washinginton State comparisons show that men in Washington State have a much higher risk of prostate cancer diagnosis and treatment and side effects of treatment, but have the same risk of death as men in Connecticut. In several papers, [including] one by me, this has been attributed to the higher rates of screening in Washington compared to Connecticut. Both have had the same decline in mortality rates.

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Friday, July 10, 2009

Congressional Republican's Healthcare Reform Questionnaire

I live in the Pittsburgh are, specifically in Republican Congressman Tim Murphys's district.

Today we received an "Important Survey on Pending Healthcare Legislation" from the Congressman. I was impressed by the straight forwardness of the questions (the subtle subtext was that you must be a complete moron to want our health care system to change) and by the clear headed, willful ignorance of the actual issues involved in reform displayed by the survey writers.

And awaaay we go...

Okay, in fairness, the first six questions weren't bad: do you have insurance, what kind, how is it, is it getting more expensive, do you believe the system is broken, and what priority should it be for Congress.

7. Do you favor a healthcare system that is run by the private sector or the government? (Private, Govt, combination, unsure)

Let's see, I want the highest quality system in the world with costs far lower than our current system. Looking around the world I see that France, a government administered single payer system is the best in the world, and Germany, with a government regulated social health insurance system administered by private, not for profit insurers is right behind it. Low cost, high quality, waiting times like ours are now... OK, I choose either Government Run like France or a Hybrid system like Germany's.

8. Would you be willing to pay higher taxes to guarantee heath insurance for all Americans?

This is why I'm writing this diary, because this question always sets me off. I would be willing to pay higher taxes because, if we do this correctly (see question 7), I will no longer be paying insurance premiums. If we do it really well (see question 7), I will actually end up paying significantly less for my healthcare overall, because we will eventually squeeze out the tremendous waste, overhead, and obscene profit currently embedded in our system.
What really ticks me off about this is the blatant intellectual dishonesty (or it could be simply ignorance, I can be charitable) on display. It does not require a degree in economics to understand that we pay for health care in many ways, but primarily we pay for it through our compensation packages: our insurance premiums come out of our wages! Ask anyone who's had stagnant wages over the past decade whether or not health care costs come out of their wages.
Have no republicans *ever* looked at a study on comparative international health care? Do they not know that we pay way more than any other country in the world. Per capita, as percentage of GDP, however you want to slice it: we have the most expensive system on the world and the Republicans seem to think the only fix is to add costs?

9. Do you think a private sector healthcare system can be improved to provide coverage to more Americans at a lower cost than a nationalized plan?

I have to confess my initial impulse was a *big NO*, but, thinking of Germany, Switzerland and the many other countries using a hybrid public-private system of Social Health insurance, I will answer a qualified yes.

If we follow the models provided for us around the world and regulate the private insurers (i.e., a 3 or 4 millimeter long leash), it can be done. The discipline that would be required for our Congress to resist the money that would surely be thrown around does make me despair that it is near impossible. But, it has been done the world over, so, I can dream, can't I?

Germany, again, provides an interesting model because it uses private, but not for profit, insurers (sickness funds) to do the administration. Everywhere in the world but here, not for profit means not for profit and not for profits don't accumulate billions in "reserve funds" or pay executives millions of dollars a year.

10. What is your main concern with your current health insurance coverage or plan? Not portable/tied to employer, lack of transparency, too many restrictions on providers/rationing, out of pocket expenses, or other.

Props where they are due for this question. I hope his Democratic constituents give him an earful on these! All of the above is the obvious answer for me, but I just have to take up the choice/rationing bit.

Republicans are always focused on choice of insurer or of insurance plans, as if where you go to the hospital or which doctor you go to is an afterthought. Like every major market in the country, Pittsburgh has essentially 2 insurers. We switched plans a couple years ago *within* one of those insurers and we went from having my wife's skin cancer specialist on one plan to her breast specialist on the other. But at least I could choose my plan!

My prior manifesto on rationing is here.

11. Should the government require that every American have health insurance?

Germany requires everyone in the bottom 4/5ths income to participate in a sickness fund. The upper fifth can opt out: 3/4 don't, leaving the wealthiest one fifth in the private market. I can live with that.

Single payer countries, you're just in. Period.

Either works for me.

12. Should the government require that all health insurance companies provide a "Basic Plan" that families could shop around?

Not the ultimate solution, but since something like this will probably find its way into the reform, here is my proposal. it comes from an old Adam Tobias book on the insurance industry called "The Invisible Bankers."

I'd like a truth in insurance statement, like a truth in lending statement on a loan or, even better, an energy sticker on an appliance. I can imagine lots of information on this sticker, but the really interesting one would be the one I stole from Tobias: *"This policy, on average, will pay out xx cents on every premium dollar paid."* I'll leave you to cogitate on that.

13. Should the government create and manage a public health insurance plan that would compete for business alongside private insurance plans?

If you've read this far, you know my answer: Well, it's better than nothing!. But, seriously, considering how un-progressive this legislation is going to ultimately be, we have to draw a line in the sand somewhere, and this should be where we draw it *at an absolute minimum.*

14. Should people on Medicaid have the option of purchasing private health insurance with a voucher to shop around for the best coverage, rather than have only the option of government insurance?

I happen to think Medicaid has lots of problems. Not the least is its very low reimbursement rates in many big states resulting in de facto rationing.

So I am against using Medicaid as the vehicle to expand coverage, but I know others feel differently.

15. Should the government offer tax credits to individuals to help offset the cost of health insurance?

I think the phrase "magic bullet" must have been invented just to cover the Republican love affair with tax cuts. Or that one about having only a hammer as a tool and every thing looking like a nail. One of those.

16. Should the government allow individuals to purchase health insurance from any state and shop nationally for the best price?

Don't care, won't help, but I can't help but notice that on issues of privacy, national security and torture, republicans say "we," but on social justice issues, it's "the government." Just sayin'.

17. Should the government mandate that private insurance companies cannot turn away patients with pre-existing conditions?

I'll vote yes, but it provides a teaching opportunity. What happens in Germany or Switzerland, you may ask, if a particular insurer gets a disproportionate care of sicker patients who cost them more? Since they can't charge higher premiums based on this and can't drop people, what happens? Risk adjustments are made and the companies get adjusted funds from the government. This is being proposed here, as well.

And finally, just to remind the pipples why they hate government and really hate all this "social justice" nonsense that the Pope and Winston Churchill are so hopped up on:

18. Any government assistance will require taxpayer funds to cover the cost. Which of the following proposals would you support to pay for health care reforms, and for the government to cover the uninsured?(nat'l sales tax, higher payroll taxes, marriage penalty, cell phone taxes, sin tax on soda, sin tax on alcohol, tax on charitable donations,raise income taxes, penalize employers for not providing insurance, tax on insurance, tax on health care expense, tax on future health care needs (?), tax on Rx drugs, raise taxes on oil refineries, taxes on power companies, taxes on US companies doing business overseas, taxes on dividend income, raise capital gains taxes, inheritance tax - phrased "tax you family assets on death" LOL.

So, if you weren't steamed before, I bet you are now. I refer you back to answer 7 for the inanity of this question, but in the best Republican tradition of ginning up resentment among the citizenry, I give you, "the list."


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ACC aghast at proposed cuts to cardiology payments in Medicare physician fee schedule for 2010

ACC aghast at proposed cuts to cardiology payments in Medicare physician fee schedule for 2010:

"Baltimore, MD - The US Centers for Medicare & Medicaid Services (CMS) has announced its planned 2010 Medicare Physician Fee Schedule (MPFS), colloquially known as 'the update,' which includes proposals expected to result in an overall payment cut of 11% for cardiology [1]."

Offered without comment, except to say scroll down and read the comments of the ACC members...

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Health Care Renewal: A Letter from the RUC, and My Reply

Health Care Renewal: A Letter from the RUC, and My Reply

This is a terrific, comprehensive review of the committee that places value on the things physicians bill for.

It is clear why procedure based specialists do so very, very well, and primary care docs constantly get the short end of the stick.

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Monday, July 6, 2009

The painful side effects of Obama's healthcare reform - Los Angeles Times

The painful side effects of Obama's healthcare reform - Los Angeles Times:

"Now, I'm well aware that having 47 million people who can't afford medical care is a genuine social problem -- although many of those millions are illegal immigrants, people between jobs and young folks who choose to go insurance-bare. I'm also aware that I can't necessarily have everything I want, whether it's a dozen pairs of Prada boots or a pacemaker at age 99. I know that Medicare is on the greased rails to a train wreck, and not just because of spiraling costs but because doctors are fleeing the system because they're sick of below-cost reimbursements and crushing paperwork. There are ways to solve some of these problems: healthcare tax breaks, malpractice reform that would lower the cost of practicing medicine, efforts to make it easier to get cheap, high-deductible catastrophic coverage, steps to encourage fee-for-service arrangements of the kind that most people have with their dentists.

"In short, as someone who's not getting any younger, I'd like to be the one who makes the 'difficult decision' as to whether I can afford -- and thus really want -- that hip replacement in my extreme old age. Sorry, President Obama, but I don't want 'society'-- that is, government mucky-mucks -- determining that I've got to go sit on an ice floe just because I'm old and kind of ugly, no matter how many fancy degrees in medicine or bioethics they might have."

Nothing like folksy wisdom for understanding and dealing with the complexities of health care reform and modern bioethics. The usual right wing disinformation and misdirection are especially tiresome. So, to the rebuttal:

First pillar of fear mongering on health care reform: rationing. Be afraid, be very afraid. Ignore the rationing (by income and economic class) that's already going on. Ignore rationing by private health insurers. Ignore spiraling costs that will soon have all but the top tiers of income earners on shoe-string insurance plans. Forget all that, just worry about the potential for rationing.

The point of Ms. Allen's piece is that health care will be rationed by using arbitrary clinical parameters to deny care based solely upon costs. Or, she also warns, that some procedures will be denied based upon scientific, non-arbitrary clinical parameters, specifically along the lines of England's National Institute for Health and Clinical Excellence which publishes guidelines and does medical and economic analyses of medical treatments to determine whether they are worth it to individuals and to society as a whole. I’m sure Ms. Allen finds it infuriating that some all other societies consider how utilization of finite resources affects everyone, not just the well off.

Interesting thing, that concept of “allocating scarce resources.” It is actually one of the centerpieces of medical professionalism developed by the American Board of Internal Medicine, the American College of Physicians and the European Federation of Internal Medicine and adopted by the American Medical Association and many other physician organizations. The Charter states, “The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.”

This brings up fear mongering pillar two, always frame the debate as a choice between our current “system” or, the systems of either Canada or England, two countries that, while providing universal health care, because of their parsimony, have performed in international health care outcomes research almost as badly as does the United States! It seems genuinely ludicrous (but convenient for generating insecurity among the under-informed) to set as the benchmark for improving our health care system two countries who only do a bit better than we do. I have yet to see an opinion piece from a conservative decrying the inferior care and long wait times in France or Germany, the top performing countries in the world. That's because they provide excellent care to all of their citizens, have no longer waiting times than our own, have much more satisfied physicians and patients and do it all at a sizeable discount to ours.

Another classic tactic is blaming the poor, the unhealthy, the “other.” On one hand, Ms. Allen laments the imposition of the 47 million uninsured onto our system, and forecasts that it will lead to unacceptable waiting times for those of us already “in.” A few paragraphs later she notes her understanding of the seriousness of the issue of the uninsured, but then posits that many of these 47 million don’t really need or deserve health care insurance as they are illegal immigrants or between jobs, etc. My brother was nearly bankrupted by being “between jobs” and having an illness in his family.

Back to our story. Ms. Allen makes a troubling conflation by muddling together limiting the amount we spend on health care in the last months of life with limiting health care to the elderly. There is a HUGE difference.

Ms. Allen cites the example of the hip fracture treatment President Obama's grandmother received before her death and the pacemaker placed into the 99 year old mother of a town hall audience member as cautionary tales, indicating the "government run" healthcare would allow these patients to simply die because some intellectual, academic physicians in their ivory towers will give the thumbs down sign and demand their euthanasia. How sad that the public's opinion of physicians and medical professionalism has deteriorated so badly that this is their expectation. Or, if not their expectation, but their cynical gambit that others will think this rings true.

Here's the difference: Obama's grandmother was terminally ill with cancer. The questions surrounding her surgery boiled down to whether it would improve her comfort in her last months and whether the surgery would ultimately shorten her life. As it turns out, it appears to have done both, making this a difficult case to slice down the middle as black and white. That's why decisions like this cause ethical dilemmas: there are pros and cons to the decisions. There are sometimes non-operative decisions involving immobilization, aggressive pain management and other palliative measures that avoid the pain Mr. Obama was rightly concerned about. And sometimes these measures, especially in extremely frail elderly patients, are the right measures, because they avoid the very high mortality associated with surgery and other aggressive measures in this population.

The medical team, had they made the decision not to operate, would not have been bureaucrats determined to painfully end the life of an elderly cancer patient, but a compassionate team of professionals, balancing the patient's quality of life in her last months (pain, hospitalization, removal from family and home, etc.), with her wishes and goals - perhaps to see her grandson elected President! When we strive to provide excellent end-of-life care, we balance all of these issues and we counsel our patients and their families as best we can because it is the right thing to do, not because it saves money. We would do it if it cost more: that is apparently the decision arrived at in this case. The calculation was made, as it should always be, based on the goals of the patient and family, not on a corporate balance sheet and potential executive bonus.

The second case, of the 99 year old requiring a pacemaker, is actually not much of an ethical problem. I agree with President Obama that these decisions should not be made based on "spirit," but they certainly can be made based upon clinical guidelines and the individual patient's health status. Regardless of this woman's spirit, if she was a frail 99 year old with advanced chronic heart or lung disease, or with advanced dementia and a feeding tube for nourishment, one would be hard pressed to justify placing an expensive pacemaker or defibrillator into her, but a healthy 99 year old is another matter. It is important to note that Medicare did not deny either of these patients care, as a private insurer may have.

The other inappropriate conflation is the issue of limiting the amount we spend with limiting the amount we spend on treatments without proven benefits or with benefits so limited as to make them frivolous in most senses. If we presume that any guideline that determines a treatment not useful to be rationing, we will be in a world of economic hurt. This is actually the point of Comparative Effectiveness Research (CER), to try to figure out what we do that is costly but adds no value to patient care on one extreme, and figuring out what is relatively inexpensive and saves lives on the other.

Her assessment of the inherent inferiority of screening mammograms every three years compared to annually demonstrates precisely the need for CER: The automatic assumption that more testing means better outcomes. This is actually one of the bigger problems with American medicine, the automatic assumption that doing something, and not just something, but the newest latest most expensive something, is always best. Should the 99 year old patient get the latest greatest pacemaker? Maybe, but having some CER to help us make intelligent judgments should be lauded, not reflexively ridiculed by the anti-intelligentsia.

Update: a link to this item on my dailykos diary and a lively discussion.

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Friday, July 3, 2009

In Poll, Wide Support for Government-Run Health -

In Poll, Wide Support for Government-Run Health -

"Across a number of questions, the poll detected substantial support for a greater government role in health care, a position generally identified with the Democratic Party. When asked which party was more likely to improve health care, only 18 percent of respondents said the Republicans, compared with 57 percent who picked the Democrats. Even one of four Republicans said the Democrats would do better."

Complete Polling Results here.

Check this out: a total of 85% said health care needed either completely rebuilt or fundamental change. And 86% think health care costs are a very or somewhat serious economic issue.

OTOH, 77% are generally satisfied with the health care they personally receive, but 94% recognize that people not having insurance is a very or somewhat serious problem. there is hope!

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Thursday, July 2, 2009

Data Note: Footing the Bill - Kaiser Family Foundation

Data Note: Footing the Bill - Kaiser Family Foundation:

"This brief data note looks at the raft of polls recently released on the public’s willingness to pay for an expansion of coverage to their fellow citizens. It compares and contrasts findings on Americans’ general inclinations on the topic, and also revisits recent findings on specific revenue raising proposals."

The file is here: Data Note (.pdf)

Kaiser does all of us a great service by doing the hard work of keeping track of and advancing our knowledgebase on health care, so my comments don't reflect on them, but...

Thanks for putting together the Data Note on polling.

I find it tremendously frustrating that the questions are asked by organizations in the manner that they are.

The question should never be "would you support raising taxes to cover the uninsured," the question should be, ""if your wages increased to reflect your employer no longer paying for your health insurance, would you be willing to pay more taxes to cover the uninsured" or, to those without insurance or buying their own, "if you could be covered by a national health insurance plan, would you be willing to pay higher taxes," or questions like that.

I note in your last section, you point to people believing that this could be done without spending any extra money. This is true, if we adopted a German style Social Health Insurance model or French style single payer model. So, these people are not being foolish, they perhaps just see the tremendous amount of waste in the system and know that if we did things efficiently we would not have to pay more (and I would add, we wouldn't have to pay more after we got through the transition period that would be required).

So I would like to see some organizations asking questions premised on wholesale reform - transformation to a German or French model - rather than continuing to be asked questions premised on rearranging deck chairs on the Titanic.

"If, rather than minor health care reform, the US adopted a system like Germany's or Frances, with high quality health care for all, no waiting times, and no danger of losing insurance or going bankrupt due to health care costs, would you be willing to pay higher taxes?"

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