Monday, November 30, 2009

A Senate Minority Hijacks Health Care - Pittsburgh Post-Gazette

A Senate Minority Hijacks Health Care - Pittsburgh Post-Gazette

According to the U.S. Constitution, each state is represented by two senators, regardless of population. This arrangement is the legacy of a deal struck in 1787 at the nation's founding, partly to keep the slave-owning states from exiting the then-fledgling nation. As a result, California, with more than 36 million people, has the same number of senators as Wyoming, with a half-million people.

That disproportional allocation has only gotten worse over time. When the Senate was created, the most populous state had 12 times more people than the least populous state; now it has 70 times more people. In the 1960s, the Supreme Court established the groundbreaking principle of majority rule based on 'one person, one vote,' meaning that all legislative jurisdictions must be equal in population. This applied to the U.S. House of Representatives, yet the U.S. Senate completely violates this fundamental principle.

As a result, the 40 Republican senators represent a mere third of the nation, meaning Republican voters have more representation than everyone else. That overrepresentation is bad enough, but it gets even worse. For the United States has added an arcane layer of parliamentary procedure known as the 'filibuster' that takes us out of the frying pan and into the fryer.

The Senate's use of the 'filibuster' means you need not a majority of 51 votes, but 60 votes to stop unlimited debate on a bill and move to a vote. So a mere 41 senators can kill any legislation. The 40 Republican senators representing only a third of the nation need to peel away only a single conservative Democratic or independent representing a low-population state like Montana, Nebraska or Connecticut to torpedo what the senators representing two-thirds of the nation want.

Given such a vastly mal-apportioned and unrepresentative Senate wielding its anti-majoritarian filibuster, it is hardly surprising that minority rule in the Senate consistently undermines majoritarian policy. Besides health care, senators representing a small segment of the nation have thwarted renewable-energy policy, sensible automobile mileage standards, cuts in subsidies for oil companies, tougher campaign-finance reform, congressional oversight of national security and war, and more.

Minority rule in the Senate has been with the nation for a long time; in fact, it is widely blamed for perpetuating slavery for decades (between 1800 and 1860, eight antislavery measures passed the House, only to be killed in the Senate). For all these reasons, two of America's most revered founders, James Madison and Alexander Hamilton, opposed the creation of the Senate, with Hamilton warning in Federalist Paper no. 22 that representation in the Senate "contradicts the fundamental maxim of republican government, which requires that the sense of the majority should prevail.

This was written by Steven Hill, "director of the Political Reform Program for the New America Foundation and author of "Europe's Promise: Why the European Way is the Best Hope in an Insecure Age," which will be published in January."

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Thursday, November 19, 2009

Evidence Based Medicine and Reform

This week has been very disappointing, with the USPSTF breast cancer screening guidelines coming out and recieving such an intemperate analysis by virtually everyone with access to a microphone or a camera.

Here is a very thoughtful analysis for those who are interested, but I'm really writing this because of what it says about us as Americans and our love-hate relationship with science.

So, researchers at USPSTF have made an evaluation and recommendations that fly in the face of "common sense." Common sense in America being that more is always better, whether it be testing or surgery or whatever. You can't be overtested, there are no downsides to excessive intervention. Except when there are. I will not go into the downsides of overtesting and overdiagnosing, but it really bothers me that we look to science to advance medicine, to make breakthroughs, to guide treatment and yet, we get a recommendation that falls outside of what we "know" to be true, we flip our collective gaskets.

Apparently, sensing opportunity, Glen Beck had on Bernadine Healy, whom I remember becasue she was in a position of responsibilityin Medicine (she was the Director of NIH from 1991-93), and she apparently doesn't care much for scientific thinking. She trotted out the old saw about prostate cancer survival being better here in America than in the UK because, obviously, the British hate their citizenry.

I have this debunking on the blog here, and it is basically that screening finds things that don't need treatment, but treating all of these cases as if they are life threatening makes our numbers look good. For a better estimate of how the US really does in saving people for dying from preventable causes, go here to see we have the distinction of being 19th out of 19.

But hearing about Ms. Healy being on glen beck reminded me that I had a letter published in US News (that's what the editor told me, though I never actually could find the link - ah, well), after she wrote an article praising anecdote above evidence based medicine. HCRenewal has an analysis here, and here is my letter:

To the Editor:

Healy castigates the practice of evidence based medicine in her polemic as if it were anathema to medical science, and, more particularly, to the individual physician's practice of medicine. Hippocrates knew that "Experience is delusory." "Experience," or anecdote, is sometimes helpful in medicine, but often harmful, because we physicians often internalize our experience into hard rules about treating patients. This often leads us down dangerous paths.

Evidence based medicine is long overdue counterweight to this kind of medical practice. EBM, when evidence is available, makes us think hard about our practices: Are we doing this because that's the way we've always done it, or because we have scientific research to back up our decisions? Sadly, it is too often the former, because the evidence is just not there or has not yet been synthesized into a useful form, or, most commonly, not yet reached the physicians "in the trenches." EBM is not discarding or devaluing physician judgment," as Healy argues, it is rather an attempt to make our judgment more rational.

I find it astonishing that Healy trumpets the jury awarding damages against a physician who did not order a PSA test based upon the best evidence available to him. Every physician should howl in protest at this outcome. Using this standard, we should all have monthly full body high speed CT scans and massive blood testing to search for every possible disorder that comes to the mind of the physician or the patient. But we do not practice this way because it is, yes, I'll say it, stupid!

Evidence based medicine is not a "straightjacket", but a means to an end: providing the best care based on the best scientific evidence we have.

So are we a scientifically based medical community and society, or are we thinking irrationally and letting fear mongers lead us over a cliff?

Don't answer that.

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Wednesday, November 18, 2009

Intellectual conservatism, RIP -

Neoconservatism -

I was once a young neoconservative. The word meant something different then, before it was hijacked by extremists by Michael Lind
A nice article on the history of neoconservatism - not what I thought - but I brought it here for this great quote:

Ultimately Milton Friedman and other free-market ideologues did far more damage to America than the carnival freaks of the counterculture.

Love it!

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Wednesday, November 11, 2009

AMA - AMA votes to continue commitment to health system reform

AMA - AMA votes to continue commitment to health system reform:

AMA votes to continue commitment to health system reform
Outlines details to guide efforts toward making the health system better for patients and physicians
For immediate release:
Nov. 9, 2009
HOUSTON – The American Medical Association (AMA) House of Delegates today voted on health system reform policies, reaffirming the AMA’s commitment to health system reform. The AMA's House of Delegates is the nation's broadest, most inclusive assembly of physicians and medical students. Delegates representing every state and medical specialty debate and vote on behalf of their physician peers.
“Now is a defining moment in the history of the AMA,” said AMA President J. James Rohack, M.D. “In a democratic process, the AMA House of Delegates today voted to continue AMA’s commitment to health system reform for patients and physicians. The time to make health system reform a reality is now.”
The AMA reaffirmed its support for health system reform alternatives that are consistent with AMA policies concerning pluralism, freedom of choice, freedom of physician practice and universal access for patients. It also outlined specific elements it will actively and publicly support and oppose as the health system debate continues.
The AMA’s support for H.R. 3962 and H.R. 3961 remains in place.
“H.R. 3962 is not the perfect bill, and we will continue to advocate for changes that help make the system better for patients and physicians as the legislative process continues,” Dr. Rohack said."

Now that the American Society of Anesthesiology has voted to support the House Bill, we now have an AMAZING NINE OF of the TEN largest physicians organizations supporting reform.

Even if you take out the AMA and AOA as a friend suggested because they are multispecialty groups, we have 8 of the ten largest physician specialty organizations supporting reform. The American College of Radiology is still against it, the American College of Emergency Physicians (# 9) has still not committed and the American College of Cardiology ( which I'm pretty sure is # 10) is on board.

That's about as close as you can get to running the table with physicians groups.

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Tuesday, November 10, 2009

How to reform the broken medical malpractice system. - By Darshak Sanghavi - Slate Magazine

How to reform the broken medical malpractice system. - By Darshak Sanghavi - Slate Magazine

For many doctors, the malpractice case against a family physician named Daniel Merenstein epitomized how the broken medical liability system drives up costs. In 1999, Merenstein, then a resident, saw a 53-year-old man for a routine checkup and discussed with him the dubious value of a blood test to screen for prostate cancer. Since the test leads to many false positives and pointless treatments that can cause impotence and other harm, neither the American Cancer Society nor U.S. Public Health Service support its routine use. Presented with the data, the patient chose not to get the test.

When the man later developed prostate cancer, he sued Merenstein and the residency training program and ultimately won $1 million. According to the plaintiff's attorney, the doctor should have ignored the evidence-based national guidelines and not even have given the patient the choice to refuse the test.

This is the same story told on This American Life last month, and it is quite disturbing. In my "to-do list" for health care reform, medical liability reform is relatively low on my list*, but this story gives me pause.

I hope we can address this and make following guide lines in good faith a reason to dismiss a lawsuit. For more information on guidelines and Comparative Effectiveness Research in action, go here.

*Caps are not even on my list, but there are many other things we can do that benefit patients AND physicians, as outlined in this Slate article, and by the AMA.

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Monday, November 9, 2009

A Christmas Carol's Social Justice Lessons...

Social Justice - Loyola Press:

Since Jim Carey's new "Christmas Carol" is number one at the box office, and we need to talk more about the moral case for health care reform in particular and with governing ourselves in general, I'm reposting this, from the Jesuits...

"In Charles Dickens's classic A Christmas Carol, Ebenezer Scrooge is visited by the spirit of his former business partner, Jacob Marley, who has come to alert Scrooge to the three spirits who will visit him in an attempt to save his soul. When Scrooge asks Marley why he is laden down with chains and irons, Marley explains that he is wearing the chains he “forged in life” as a punishment for not making better use of his time on earth. Scrooge protests, “But you were always a good man of business, Jacob.” To which Marley laments, “Business! . . . Mankind was my business! The common welfare was my business; charity, mercy, forbearance, and benevolence, were, all, my business. The dealings of my trade were but a drop of water in the comprehensive ocean of my business!”

There's more, and I thought it is still a nice Christmas message...

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Sunday, November 8, 2009

House Bill Effects on Physician Income

I had a piece in the Pittsburgh Post-Gazette today on physician support of health reform.

A sadistic friend posted it on Sermo. Weee!

The subject of the effect on physician income came up on our Doctors for America and I said:

I often ask my colleagues who 1.) complain about Medicare rates and 2) say all care for the uninsured should be via charity by physicians , "Wouldn't you rather get paid a bit less and have everyone covered so you have more paying patients?"

I doubt anyone has done an analysis of what the net effect of this would be, but perhaps the net effect would be neutral or positive, I don't know. BUT as the NEJM survey said, most of us find it acceptable to take lower reimbursements if everyone is covered.

Our terrific Media Mogul, Mandy Krauthammer-Cohen, MD, of course, had a great bit of information:

Some additional food for thought. If you look at the Lewin group analysis....which does have a conservative bias given it is owned by United Health...physicians will actually make more money under health reform with a public option.

Testimony by Lewin states: "In the first year of the program (when public option is only opened to small businesses with less than 10 employees), physician income would increase by $10.9 billion. This reflects the reduction in uncompensated care for uninsured people as well as increased health services utilization for newly insured people. It also reflects the House bill provisions that would increase Medicaid reimbursement for primary care services to Medicare payment levels. Thus, the reductions in payment for people who shift to the public plan are outweighed by increases in reimbursement for Medicaid, reductions in uncompensated care and revenues from increased service use for newly insured people. Average net-income per physician wouldincrease by $15,237 in 2010 under this scenario."

Read the whole testimony here.

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Monday, November 2, 2009

T.R. Reid: Can We Really Fix U.S. Health Care?

From the Commonwealth Club of California Podcast is here.

Friday, September 18, 2009, 12:34:52 PM

T.R. Reid, Correspondent, The Washington Post; Commentator, National Public Radio; Author, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care

For 100 years, U.S. presidents have unsuccessfully strived to provide universal health coverage. When LBJ created Medicare in 1965, he thought the program would gradually be extended – to people over 60, then 55, then 45, etc., so that everybody would have government health insurance by 2000. Decades later, the Clinton plan failed. George W. Bush created Medicare Part D. Barack Obama says we have the best chance ever this year to fix our health-care system. Is he right? Reid weighs in and reveals what we can learn from health-care models across the globe.

This program was recorded in front of a live audience at The Commonwealth Club in San Francisco on September 14, 2009.

A very good listen. Excellent tid bits about health promotion in Britain, insights into the minds of Canadians and more!

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