Sunday, May 31, 2009

In Memoriam George Tiller

George Tiller was murdered today. In church. His church. While serving as an usher at Reformation Lutheran Church. In Wichita, KS. His town. Presumably by a believer in the “right to life”. Cowardice doesn’t begin to describe it. Outrage cannot begin to describe our feelings.

We know why he was murdered. He was a family doctor who performed abortions. The story is that when he took over his father's general practice in Wichita after his father's untimely death, one of his new patients asked George if he would provide abortions "like your father did". It was the first George knew that his father did abortions, so he decided to learn how to do them. He became one of the most well-known, and, as a consequence, most reviled, abortion providers in the US. He was one of the few physicians, especially in this center of the country, to provide second-trimester abortions. He was 67 years old. He leaves his wife of 45 years, four children – 2 of them physicians – and 10 grandchildren.

Dr. Tiller did not know that his father did abortions because, at that time, before Roe v. Wade, it was illegal, and it was kept quiet. Dr. Tiller himself did not keep quiet about it, despite being a quiet and soft-spoken and gentle man. It was impossible, for the noise came to him. In 1991, “Operation Rescue” came to demonstrate in Wichita against Dr. Tiller. In his book “What’s the matter with Kansas?”, Thomas Frank cites this as a turning point in that city’s move to the right. In more recent years, Dr. Tiller was the victim of a vendetta by the virulently anti-abortion former Attorney General of the state, Phill Kline. Coming to trial earlier this year, after Kline had left the office, the case was decided by the jury in minutes. They threw it out. So his opponents found another way to stop him. A permanent, horrific way. A way that marks them as without morality, much less a morality that could judge another. Amazingly, papers like the NY Times are interviewing people like Kline and the leaders of Operation Rescue. This is like interviewing members of the Ku Klux Klan about the murder of Dr. King.

The majority of doctors who perform abortions are older. This is probably because they remember, not so long ago, not 40 years ago, when abortion was illegal. And what that meant. It meant the deaths of women. Women die from illegal abortion. The doctors who performed them before it was legal, and those who, like Dr. Tiller, continued to perform them despite the threat of death, did so because they wanted the women who chose abortion to be able to have it done safely, to not risk their lives with coat hangers in back alleys. The countries in which abortion is illegal have higher rates than those in which it is legal, mainly because those same countries restrict access to accurate sex education and to effective contraception. When abortion was illegal in the US, and still where it is unavailable in the US, and where it is illegal around the world, women still have abortions. They always have. The only difference is that they do not have them safely. Younger people – men too, but especially women – need to know that the right to an abortion is not one to be taken lightly, not one that has always been there, not one they can count on to always be there when they, in their unique and special and unlike-all-those-others circumstances, need one.

George Tiller had been shot before, in both arms. He went to work wearing a bullet-proof vest. (I guess he didn’t wear one while serving as an usher in church.) It didn’t stop him from serving the women who came to him in desperation. It would have stopped many, but not this gentle and compassionate physician. Now he has been stopped.

Let us get right down to it. You may be opposed to abortion. You may think people shouldn’t get abortions. You may do your best to talk people out of getting abortions. You may even believe abortion is murder. However, you are not involved unless you are the woman who is pregnant. If you are that woman, and you choose to continue your pregnancy, great. George Tiller would have been your strongest supporter. If you are not, if you are not the woman who is pregnant, if you are a man, your only job is to support the decision of the woman who is making it.

Life is not always as we would like it to be. Goodness knows, it sure isn’t and hasn’t been always how I would like it to be. But whatever you want to be true, the fact is that people get pregnant who don’t want to be and didn’t intend to be and can’t see how they can birth and raise a child. And no matter how much you believe in adoption, look around you and see the number of orphan children and children in foster care, not to mention the children in unsafe and abusive homes. No matter how much you are against abortion, no matter how hard you make it, women will have them.

So far, the anti-abortion movement in the US has not largely suggested or pushed for the punishment of women who have abortions. We are not, yet, the Taliban. So we kill the doctors instead. I know that most people who are active in the anti-abortion movement would not commit such a murder, but they have to take responsibility for creating a situation in which a murderer would think they were doing the right thing. We all have to take personal responsibility for the implications of our positions.

Dr. Tiller's motto was "Trust Women". Those who work to restrict abortion do not. That is the difference.

George Tiller will be deeply missed.

Thursday, May 28, 2009

"The Nation"'s Health Care Bottom Line is Bottom of the Barrel

I was initially surprised at reading the editorial "Healthcare Bottom Lines" by J. Douglas Feder in the ostensibly progressive Nation (June 8, 2009) After rereading it I was both shocked and disappointed that the Nation would feature this as an editorial. It could truly have been placed by Max Baucus' publicist.

For starters, the piece doesn't even mention the single-payer option. Even the New York Times disagrees with Baucus and other Democratic leaders saying that this being "off the table". A single-payer plan, such as the improved and expanded Medicare for All program that is called for in Rep. John Conyers' HR 676, which has 100 co-sponsors in the House, is the only proposal that will both cover everyone and save a lot of money. Nothing else comes close. More important, it is not only supported by a lot of Congresspeople, but a lot of the public. Single payer is the ONLY proposal with a mass movement of church groups, labor unions, consumer groups and others behind it. Every other proposal has as supporters politicians, policy wonks, academics and talking heads, but no mass movement. Over 60% of the American people support such a plan in poll after poll, and even 59% of physicians support it. How can a magazine such as The Nation not even mention it in an editorial?

Feder cites three "top points" that must be considered in health reform, and all are misdirected. His first, "The public plan must rein in costs" ignores the most important way that costs can and should be reined in: by eliminating insurance company profit. Even those first-world countries without a single-payer system have only non-profit health insurance companies. While other methods of controlling the growth of costs must definitely be pursued, the elimination of profiteering generates a huge initial drop in cost. If there is only a public “option”, rather than a public single-payer, the savings will be real but will be much reduced as providers (doctors and hospitals) will need to maintain their enormously expensive billing and collecting infrastructure. Feder’s second point "The public plan must fix uncompetitive markets" follows the tortured logic necessary if one believes that we need to maintain the private, for-profit companies, which is a bad idea (see above).

Finally, Feder says "medicine must be practiced more cost-effectively", noting that "…$700 billion a year -- one in three healthcare dollars -- goes to treatments that have not been shown to improve outcomes". Well, yes, this is an issue, but both here and in his discussion of his first point, Feder seems to be calling for payments to physicians to be cut across the board. He does not address the most important issue, which is that our system (or non-system) is built on tertiary care, paying for enormously expensive (and to be sure, often unproven) treatments but not for the care coordination and prevention that characterize primary care. Overwhelming research, by Starfield and her colleagues at Johns Hopkins, by Wenner, Baicker, Chandra and colleagues at Dartmouth, as well as many others, show that systems built on primary care -- in this country and across the globe -- have lower costs and higher quality. Tom Daschle, for goodness sake, in his ill-fated confirmation hearings, rightly showed the US as an upside down pyramid: while other counties begin by spending on primary care and go up to secondary and tertiary care until the money runs out, the US does the opposite. With terrible results. The Patient-Centered Primary Care Collaborative ( was begun by international corporations that realized that their costs were lower and the quality was better in countries where the health system is primary care based, in contrast to the US. The perverse tertiary-care, subspecialty-based payment system we have means that our already low primary care component (about 30% compared to a desirable 50-60%) will get even worse, as medical students are entering primary care at rates close to 20%. Feder, the Nation editorialist, ignores this entirely. That these issues are much better addressed by the New York Times, Tom Daschle, and IBM (through PCPCC) is a complete embarrassment for The Nation.

Let me reiterate the two important points:
The US needs a system built around primary care, one that increases the incentives to enter primary care and increases payment for primary care. A plan that does not do this fails the American people. It also needs to save the extraordinary percent of our "healthcare" dollar not spent on healthcare, but on corporate profit. These are the two important points, not those of Feder. It is hard to believe that The Nation is so out of touch with its readership and the American people.

Monday, May 25, 2009

Funding Graduate Medical Education

In the spirit of writing about seemingly boring (ok, maybe really boring!) but important policy topics I am going to talk about the funding of Graduate Medical Education (GME). First some background (may be TMI, but you gotta know this to understand the issues). GME, commonly known as “residency training” is where medical school graduates, after receiving their MDs, go to really learn how to be doctors in their specialty of choice. While most (but not all) states still allow physicians to be licensed with only one year of post-graduate training (“internship”), one can only sit for specialty boards (become “board-certified”) after completing an entire residency. These core residencies range from 3 years (for internal medicine, family medicine, psychiatry, pediatrics) to 5 years (for surgery). In addition, there are “fellowships” of 1-3 years that prepare graduates of core residencies to become subspecialists (e.g., cardiology, gastroenterology, endocrinology in internal medicine or pediatrics, or thoracic and cardiac surgery, etc.).

Currently, most GME is funded through Medicare, with supplemental payments to hospitals that train residents. The amount varies by hospital based on two characteristics: what percent of patient bed-days are Medicare (easy to understand; if you would get $X per resident if all your hospital bed days were Medicare, you get 50% of $X if 50% of your bed days are Medicare). The other, what is $X for your hospital, is virtually impossible to understand, as it is has its origins in the cost-reports submitted by hospitals in 1985, two years before the legislation established GME support was approved. The important point is that there is a wide variation in what $X is between hospitals, with public hospitals tending to be on the low side and NYC teaching hospitals at the top. The skew was so great that the lowest were brought up a few years ago, but the balance, bringing down the top, did not happen. Furthermore, GME $ are divided into two pots, Direct GME (DGME), intended to pay for resident salaries and benefits and the teaching time of faculty, and Indirect ME (IME) expenses, intended to pay for something, which varies by who is explaining it. I will append my explanation at the bottom[i] to not get any farther afield, but will note that the IME $ are often twice the DGME $, and so are no small issue.

In addition to the problems identified above (why is there skew between hospitals in what the core support of residents would be, and what the heck is IME and what is it for?), there are two other big problems: What sense does it make to have Medicare $ funding GME, and why do all the $ go to hospitals? Regarding the first, since all doctors who care for all people have to be trained, why should Medicare be the only payor to pay for it? Why not other insurers? It is not unimportant, since, as noted, the larger the percent of Medicare patients the larger the GME payments. This is a second characteristic discriminating against public hospitals; in addition to their $X being worse because of the 1985-cost-report issue, public hospitals are more likely to take care of a smaller % of Medicare patients for two reasons: 1) Medicare patients have more choice, while uninsured younger people do not, and 2) a disproportionate percent of younger people who need to be in the hospital, because of lack of medical care that would be able to prevent hospitalization and because they are more likely to be exposed to violence, drugs, etc., are poor, uninsured, and thus not admitted to non-public hospitals. It makes absolutely no sense to not have GME funded by a separate educational appropriation not tied to Medicare – except for politically. As long as it is tied to Medicare, funding is more likely to be assured; if it was a separate appropriation, it would be an easier target for congressional budget cutters. Think back on de-institutionalization of the mentally ill. It made perfect sense to close the frequently-inhumane warehouses that were public mental hospitals because drug therapy meant that patients could be cared for effectively in the community by community based mental health centers. Except we closed the hospitals, and then have continually cut the funding for community-based mental health centers. VoilĂ ! Large numbers of untreated homeless mentally ill people on the streets! Medical educators are very leery of this repeating in the GME arena if it is no longer tied to Medicare.

The other big issue, why GME $ go to hospitals, is one that definitely should be addressed. This blog, and many other places, have pointed out repeatedly the shortage of primary care physicians to meet the access and quality health needs of our population. Yet GME rules allow hospitals only to declare the time of residents spent in the hospital, or in hospital-owned clinics. Many of the ambulatory practices that family medicine and other primary care residents are trained in are not owned by the hospital – they may be owned by the medical school, a practice group of faculty, or a non-profit corporation. In addition, if the residency sees the best training to involve rotations with community-based primary care or specialty physicians, or in public health settings, the hospital cannot get GME $. Therefore, it is in the interest of the hospital to keep the residents in hospital settings, not necessary where they will get the best training to be community-based doctors working primarily in ambulatory settings. Hospitals would prefer to use GME $ to fund training of residents and fellows that perform services that bring in revenue to the hospital’s bottom line; for example, training more cardiology fellows who extend the amount of these highly-profitable services that can be done by the supervising physicians. There MUST be a change in policy so that GME $ from Medicare for family medicine and other primary care residency training goes directly to the training program, not to a hospital. The training program can then pay the hospital (or multiple hospitals), or community doctor, or public health venue, as appropriate for the time spent in resident training.

Each hospital has a GME “cap” of the number of positions it can have funded by Medicare. There have been repeated calls from organizations such as the Association of American Medical Colleges to lift, or raise, the caps, by as many as 15,000 positions per year. The argument in favor is that simply increasing the number of doctors produced (by creating new medical schools and increasing class size in those that exist) will not increase the number of physicians if the GME slots are not increased; US grads will simply occupy slots currently filled by international medical graduates (IMGs). This is a VERY wrong proposal. Absent changes that will make entering primary care residency training more attractive to US medical students (read $: both in loan repayment and increased payment for primary care), it will just further skew the balance of physicians toward subspecialists. For one thing, as noted above, those are the specialties hospitals wish to fund. For another, many US graduates entering primary care are doing so because it is easier to get into these residencies because there are limited numbers of “slots” in the more lucrative specialties. If the number of residency positions in those specialties are increased, it will decrease the percent of US medical graduates entering primary care, which is already at crisis levels. (see “More primary care doctors or just more doctors?”, April 3, 2009.) The evidence shows that even without raising the cap, hospitals are funding more positions from their own money – and these are absolutely NOT primary care. In recent years subspecialty residency slots have increased almost 30% while primary care positions have decreased almost 3%!

GME funding needs to be reformed, and the first step is to directly fund primary care residencies. This needs to be accompanied by payment reform to make careers in primary care less unattractive compared to subspecialty care. And it needs to happen now, as part of health reform.

[i] OK, IME. Hospitals – who want to keep the money rather than spending it on resident education – say it is for making up their cost because residents order more tests. Maybe, but if there were no residents, there would be no IME $, and they’d have to hire someone else to do the work. Obviously, senior physicians would be prohibitively expensive, but even Nurse Practitioners or Physician’s Assistants would cost nearly 4x as much. Residents work about twice as many hours for about half the salary of NPs or PAs. And, as physicians, they have a broader scope of practice. They are certainly the most “cost-effective” employees in a hospital. A better argument for IME is that hospitals with residency programs – university hospitals, public hospitals, and large not-for-profits – get sicker patients (which they do, both because these are the safety-net and tertiary care hospitals, and because the residents mean there are round-the-clock doctors). Thus, IME is another form of disproportionate share funding for such hospitals.

Thursday, May 21, 2009

Primary Care, Pediatrics, and Physician Distribution

As the discussion on health reform proceeds, we are seeing several “specialized” takes on what form health reform should take, what the interests that are advanced should be, and to what degree the current privileges (income) of those who are doing particularly well in the current arrangement (insurance companies, pharmaceutical and medical device companies, many hospitals and subspecialist physicians) should be preserved; this latter is sometimes couched in terms of benefit to the health of the public, but sometimes the argument is even made de facto. In this an a future entry or two, we will discuss some of these issues regarding the physican workforce, physician training, and financial incentives.

In the May 13, 2009 issue of JAMA, Freed and Stockman write on “Oversimplifying primary care shortages”.[1] Citing the literature demonstrating the shortage of primary care physicians, they assert that the real issue is that there is a shortage of primary care physicians for adults, and that the production of primary care pediatricians has not suffered. “The most recent published data regarding pediatric residents completing training in 2008 demonstrate that 40% were planning to pursue a career in primary care, with 10% still undecided.” They warn against increasing the production of general pediatricians, fearing an oversupply, noting that “While the absolute number of children has remained relatively stable, the number of pediatricians has increased substantially. This has resulted in an increase in the number of primary care pediatricians, from 32 to 78 per 100,000 children in the period 1975 to 2005.” They then go on to talk about the “…increase in the number of recognized subspecialties [in pediatrics] and the continuing need to populate those fields with fellowship-trained pediatricians.”; essentially an argument for the need for more pediatrics residents to choose subspecialty training. I will not address that except to say that this statement, unsupported is a tautology – because we have more specialties we need to train people to go into them – rather than a justification (which may well exist) for the need for more pediatric subspecialists.

The fact that the entrance of medical students into pediatrics, and the stability of the choice of general pediatrics among those residents, the first in marked contrast to the decrease in students entering family medicine and the second in contrast to the career choices of residents in internal medicine, is definitely important. It is worthy of more than note; it needs to be studied to identify the reasons. Perhaps these reasons will be unique to pediatrics and not transferable to other primary care (adult) specialties, but perhaps there are important lessons to be learned. However, a gross measure, in this case total number of pediatricians, or even primary care pediatricians, to the number of children misses some important considerations, many of which have been addressed previous in this blog. The most obvious is that Freed and Stockton completely ignore geographic distribution of pediatricians, a point noted by JAMA editor Catherine DeAngelis in her editorial. “…although the number of generalist pediatricians does not appear to be a problem, their geographic maldistribution remain.”[2] Pediatricians, like most physicians, choose to locate in certain areas, specifically in major metropolitan areas. Rural areas especially, and to a lesser degree inner-city areas, do not have enough pediatricians.

Indeed, it is only family physicians that distribute in proportion to the location of the population. Freed and Stockman are correct in asserting that we do not need to simply train more primary care pediatricians, but the reason is that they have saturated the areas in which they are willing to live. This is addressed in Dr. Robert Bowman’s guest column on this blog from January 15, 2009, “Ten myths regarding primary care”. Myth #9 is “The nation needs more pediatric graduates to meet primary care needs.” Dr. Bowman states “More pediatric graduates will not meet primary care needs. According to pediatric leadership, pediatric primary care is saturated in the locations where pediatricians choose to locate, at the same time that the United States has fewer children. Even though 15% of white female medical students remain committed to pediatric residency choices, they and other pediatric graduates will compete with all other primary care graduates already delivering pediatric primary care. This is likely to result in more practicing in part time, specialty, hospital, urgent, and emergent pediatric care settings.”

The fact that pediatricians are disproportionately female may help to explain the relative immunity of this primary care field from downturns in student selection, but, for the reasons Dr. Bowman identifies, may not solve our geographic distribution needs. It may also explain why simply looking at the numbers of doctors entering a specialty (general pediatrics in this case) may overestimate the actual number of FTEs and years practiced (Dr. Bowman’s “Standard Primary Care years). As this blog addressed on March 7, 2009, “The feminization of medicine” is in many ways a very good thing – including the persistent interest in pediatrics – but it has other implications which need to be considered in estimating workforce supply. These include the probability that female physicians, including pediatricians, will work fewer years (including time off for child rearing and earlier retirement) and the greater likelihood of female physicians to work less than full time. In addition, while there are great difficulties in getting physicians overall to practice in rural areas, the issue is even greater for women, because they are even more likely than male physicians to be married to other professionals, frequently physicians in more lucrative subspecialties, who cannot find employment in rural areas.

The challenges of getting physicians to rural areas are enormous, and have been addressed here before. Increasing the number of rural students is critical; paying doctors who work in “less desirable” (and here I want to make clear that this is not by any means a value judgment on life in rural areas, but simply a reflection of physician choice; maybe we should say “less popular”) rural areas more money than those who work in urban areas is essential. But it also requires producing the kind of doctors who can work in those settings, and essentially that means family physicians – and probably general surgeons. If students continue to enter family medicine at rates that won’t even replace the already-too-low percentage of primary care doctors, then all strategies need to be developed to encourage them. It is not sufficient to increase reimbursement for generalists a little, or even some; the entire reimbursement structure needs to be revised to encourage continuity, comprehensive management, coordination of care, and quality metrics rather than production of visits or procedures.

[1] Freed GL, Stockman JA, “Oversimplifying primary care shortages”, JAMA 13May09;301(18):1920-22.
[2] DeAngelis CD, “Commitment to care for the community”, JAMA 13May09;301(18):1929-30.

Saturday, May 16, 2009

Health Care Industry Pledge to Cut Costs: No News at All

The big news on health care reform last week, when at a press conference, President Obama announced that the “Health care industry is said to promise to hold down costs voluntarily” (New York Times, Monday May 11, 2009, p. A11; p. 1 in the Kansas City Star), turned out to be no news at all when 4 days later the Times reported that “Health care leaders say Obama overstated their promise to control costs”. Actually, while it may have been news, it was never serious or real; rather it was a desperate attempt by these players to derail serious health care reform (an effort which still well may be successful).

Apparently, much of the impetus for this press conference came from the Service Employees International Union (SEIU), bringing together insurers (America’s Health Insurance Plans), the Pharmaceutical Research and Manufacturers of America (PhaRMA), the Advanced Medical Technology Association (AMTA, representing device manufacturers, such as Medtronics – see recent columns), the American Hospital Association (AHA) and the American Medical Association (AMA). This allowed the President to announce “These groups are voluntarily coming together to make an unprecedented commitment. Over the next 10 years, from 2010 to 2019, they are pledging to cut the growth rate of national health care spending by 1.5 percentage points each year – an amount that’s equal to $2 trillion.”

Note that this is cutting the “growth rate”, not cutting the cost. Nonetheless, it would be not insignificant. If it were real. But even before the rapid backpedaling reported on May 14, observers were noting that there was no “there” there. “It was a promising event, but probably not the ‘watershed event’ that President Obama had proclaimed it,” opined a Times editorial on May 13, ”So far, all we have is a vague and unenforceable promise that may never materialize.” By the 14th, the signatories to the letter reported that they could not even deliver their constituencies: “There’s been a lot of misunderstanding that has caused a lot of consternation among our members” (president of AHA), “The groups did not support reducing the rate of health spending by 1.5 percentage points annually” (executive VP of AHA), “...`there was no specific understanding’ of when the lower growth rate would be achieved” (EVP of AMTA). The Times reports that “Nancy-Ann DeParle, director of the White House Office of Health Reform first said ‘the president misspoke’ on Monday and again on Wednesday when he described the industry’s commitment…” but “…called back an hour later…and said ‘I don’t think the president misspoke.” Clear as a bell.

So what does this all mean? Is it a good thing or a bad thing? Certainly the fact that these big players in health care felt the need to say something is important. Most of them represent companies and groups (such as doctors and hospitals) that we will need to have in the American health care system when we finally get one. We’ll need doctors and hospitals and even pharmaceutical and device manufacturers (if, hopefully, not as rapaciously profit driven and often corrupt as they are now). America’s Health Insurance Plans? Maybe not. So maybe it is significant that the group that felt that it could defeat health reform in the early 1990s with its “Harry and Louise” commercials (correctly, apparently, with some help from an incredibly arcane Clinton plan) signed on.

The worst part of this whole episode is not the quick backtracking of most of the participants came well before any “concrete proposals”, as the Times May 13 editorial called for. It is that the President, presumably on the advice of his health care “team” such as Ms. DeParle, gave such prominence to this nonsense at all. In the first place, we don’t just need to “slow the growth” in costs (and we do need to), we need a huge cut in the cost of health care to start out. This can come through a single-payer type of Medicare-for-All program that dramatically cuts the administrative costs of our system while, oh yeah, also covering EVERYBODY. (I’m sorry; I can’t say this enough. NOT more kids, more middle-class people, more poor people, more people with pre-existing conditions, but EVERYBODY. This is not just for moral reasons – though they are enough – but for saving money. The cost of programs and bureaucracies to figure out who is eligible and who is not is astounding!) Then, after we get this big one-time savings, we need effective mechanisms to control the growth of costs, including ones I’ve previously discussed, such as clinical practice guidelines and technology assessment (May 12, 2009), controls on drug and device costs, use of generic drugs, etc. Increased efforts for prevention is very good and important but may not save money (see previous entries, Feb 13, 2009).

The pharmaceutical and device makers would continue to make profit, but a lot less. That is a good thing. The insurance companies could stay in business but only as plan administrators as they are now for Medicare, not as for-profit entities. That we allow insurance companies to be for-profit in this country, unlike most, is the biggest obstacle to real health savings, both directly because of the cost and indirectly because of the tenaciousness with which they will use their wealth and power to fight any real change. As Paul Krugman pointed out in his otherwise surprisingly optimistic column on May 11, “Remember that what the rest of us call health care costs, they call income.”

It is going to take a lot of work by the rest of us to overcome the influence and wealth of those of call it income. Do not underestimate that power. Just this week, on another issue, 2/3 of the US Senate voted against limiting the usurious interest rates often charged by banks on credit cards as well as pay-day lenders and others. There is no way to describe this other than a clear statement that says “We are in the pockets of the banks.” These are the same banks whose terrible policies caused the collapse of the world’s economy and required huge federal bailouts, and the Senate still votes their interests over those of the American people. So assume nothing. Keep the pressure on. If you care about genuine health reform, you have to repeatedly, clearly, and insistently let your representatives know. The “health care” (more properly the “make profits from dollars that should be spent on health care”) lobby is taking them to dinner.

Wednesday, May 13, 2009

Addendum: Medtronic back in the news

The Medtronic company, manufacturer of the devices found 15 years ago to be ineffective in acute pain by AHCPR (May 12 post), is back in the news today -- tied to the Walter Reed Medical Center surgeon who the Army says falsified data. In an article by Duff and Barry Meier in the New York Times, "Doctor Falsified Study on Injured G.I.’s, Army Says" ( we read:

"A former surgeon at Walter Reed Army Medical Center, who is a paid consultant for a medical company, published a study that made false claims and overstated the benefits of the company’s product in treating soldiers severely injured in Iraq, the hospital’s commander said Tuesday....The former Army surgeon, Dr. Timothy R. Kuklo, reported that a bone-growth product sold by Medtronic Inc. had much higher success in healing the shattered legs of wounded soldiers at Walter Reed than other doctors there had experienced, according to Colonel Coots and a summary of an Army investigation of the matter."

I guess this leopard, Medtronic, has not changed its spots!

Tuesday, May 12, 2009

Clinical Guidelines and Technology Assessment

“Clinical Guidelines and Technology Assessment”? Well, there’s a yawner!

Maybe you'll be one of the few who won’t say “I think I’ll skip this one”, but if you are not, I’d have to be empathic. I’m thinking about the time I picked up a “Technology Assessment” document (I think it was on the use of lithotripsy for ureteral stones) issued by the Agency for Health Care Policy and Research (AHCPR), now known as the Agency for Health Research and Quality (AHRQ). It was a long time ago because, as noted by Barry Meier in the Business section of the New York Times (May 7, 2009), in his article reporting on efforts to re-institute Federal guidelines for procedures and technology through ARHQ, it has been 15 years since they have been issued.[1]

Meier's piece begins by focusing on the last time that ARHQ (then AHCPR) did publish such guidelines in the 1990s, they ran into big trouble. Specifically, the guideline that did not recommend spinal fusion for acute back pain generated attacks by spine surgeons and device manufacturers that were far more than verbal:
One medical device maker, Medtronic, sued unsuccessfully to block its release. Republican lawmakers tried to kill the agency that issued the report. It survived, but its funding was drastically cut and it decided to stop issuing guidelines.”

So what’s the problem? Well, the evidence showed that these fusions did not, on the whole, work. The evidence was there to support the AHCPR guidelines; indeed, for the federal agency, that was the whole goal, to review the evidence; they had no “skin” in the outcome. But for spine surgeons and device manufacturers, such a recommendation would lead to loss of money. Unable to respond on the evidence, they tried strong-arm bully-boy tactics. Which largely worked. AHCPR, then AHRQ, has issued no guidelines since. Until this year, with the Obama administration appropriating $1.1 billion for technology assessments and prepare guidelines (only $400 million going to ARHQ, the only agency that has a history of doing and funding such work; the rest is inexplicably going to NIH and others), there haven’t been any such guidelines issued for 15 years. How does this help the American people?

Not at all. Guidelines based upon evidence that help physicians choose between alternative therapies for different conditions would only be beneficial to our health: “Supporters include many medical researchers, consumer groups unions, and insurers [and, indeed, physicians]. They say such studies are essential to curbing the widespread use of ineffective treatments and to helping control health care costs, which totaled $2.2 trillion in 2007, or 16% of the nation’s gross domestic product.”

It would seem to be difficult to argue for using “ineffective treatments”, but that would only be if you were not the one to profit from it: “…potential opponents, which include medical products companies, some doctors and their political allies, warn that the comparative effectiveness movement could lead to inadequate treatment for some patients and even the rationing of health care.” Wait a minute. How does knowing that some treatments are more effective than others, or that some treatments are virtually ineffective, lead to inadequate treatment? Are we sure that they are not talking about inadequate profit? And what about rationing? What do we have now? Those who are well-insured get everything, whether it works or not, whether it has the potential to do harm or not, while those who are not insured get nothing, even when we know it would work. How is this better?

These opponents argue that such guidelines would decrease “personalized medicine”. “Personalized medicine” sounds good until you look into it, when you might well ask “but on the basis of what evidence are you personalizing my treatment?” Unfortunately, often it is at best doctor preference and at worst driven by opportunity to make money. This issue is addressed by three “Perspectives” in the May 7, 2009 isssue of the New England Journal of Medicine. Garber and Tunis point out that “personalization” requires the evidence; for example, that bypass surgery has lower mortality for coronary disease in people over 65, while angioplasty is better for those 55 or less. They note that the greatest “personalization”, understanding your genetic makeup, requires studies to look at how much a particular gene affects a person’s likelihood of getting a disease or responding to treatment; that is, how well such testing strategies work.[2] Naik and Petersen discusses the purposes of comparative-effectiveness research, and examine the three levels needed to decide if it will work in actual people[3]. Avorn directly takes on the opponents of such research, including demagogues such as Rush Limbaugh.[4]

The leader in this effort is a new industry lobbying group, the “Partnership to Improve Patient Care” (don’t you love these names, picked to entirely obfuscate what they are really about? It does sound a lot better than “the Partnership to Maintain our Profits”, a name that would fit it, and indeed virtually all of these lobbying groups). Its spokesman is former California congressman Tony Coelho, a former Democratic whip. He is “former” because he resigned in the wake of a junk-bond investment scandal. So it is certainly not surprising to see him fronting for such a group; he is well-paid, we can be sure. One of the bugbears raised by these opponents is the British government’s National Institute for Clinical Effectiveness (NICE). (Now isn’t that a nice name?) NICE evaluates the clinical effectiveness of various interventions and also associates them with a price tag – how much will it cost to treat enough people that one person will have an improvement of a certain amount of quality life (usually measured in quality-adjusted life years, or QALYs). This concept takes into account the number of people that would need to be treated for a beneficial effect to be seen, the percentage of people who will see a benefit, and the degree of that benefit. By looking at the cost to do this intervention in enough people to result in an increase from the therapy of 1 QALY, different treatments can be compared to each other. Thus we can see the relative benefit, and cost-benefit, for different treatments for the same disease, as well as assess where there is more “bang for a buck” in funding treatments for different diseases.

In Britain, the governmental NHS has used recommendations from NICE to deny coverage for treatments that exceed a certain cost-per-QALY, and has predictably come under some criticism for this. But the criticism generally, and rightfully, is related to the question of what the appropriate cost is. It is clear that $5000 (or pounds) per QALY is well worth it; it is also clear that $500,000 is extremely high, probably too high. In the US, there is no plan for AHRQ to even assess cost as part of its guidelines, not to mention use that as basis for reimbursement.

But it is probably true that Medicare, as well as private insurers, are unlikely to pay for procedures which, on the basis of the evidence, are assessed to be ineffective or significantly less effective than alternatives (indeed, many insurance companies have long had preferred drug lists, with 3-tiered co-pays, preferring generic, lower cost drugs). This would be, on the whole, a good thing, for cost control and for quality of patient care. But it would be bad for the profits of companies that make products not judged to be effective and the physicians and surgeons who currently make money from using them, just as with the spinal fusion issue in the 90s. And they have power, and clout, and lobbyists like Tony Coelho.

Ironically, research in basic science laboratories, the kind that is most of what is done with the $30 billion NIH spends, tends to be uncontroversial. By its nature, it is unlikely that any particular study of this kind will ever have an impact on the health of people, and if it does, the likelihood is that it will be decades before that is seen. So it rarely hits any individuals or companies in the pocketbook (we ALL pay for it in tax dollars). In contrast, the paltry (even with the increase to $1.1 billion) funding for ARHQ generates a lot of opposition because it actually assess existing approaches to treatment and makes recommendations as to which are most likely to benefit people.

Duh. Don’t we want that? Avorn notes that “Fortunately, Congress did not let warnings of a dystopian scientific police state undercut the nation’s need to learn what works best in medicine.” But he warns that while comparative-effectiveness research “…dodged a barrage of well-coordinated bullets this time, the debate is bound to continue.” I agree; the battle may be won, but the war is not over. Given the well-funded opposition, it will be critical for the American people to let them – physicians, industry, lobbyists, and their lawmakers -- know that we want our government to support research that may actually benefit us.

[1] Meier B, “New effort reopens medical minefield”, New York Times, May 7, 2009, pB1
[2] Garber AM, SR Tunis, “Does comparative-effectiveness research threaten personalized medicine?”, NEJM May 7 09;360(19):1925-7.
[3] Naik AD, LA Petersen, “The neglected purpose of comparative-effectiveness research”, NEJM May 7 09;360(19):1929-31.
[4] Avorn J, “Debate about funding comparative effectiveness research”, NEJM May 7 09;360(19):1927-9.

Friday, May 8, 2009

What is wrong with the idea of "Consumer Directed Health Care": A "Technical" Answer to the "Thought Experiment"

Dr. Frey's "Thought Experiment" led colleague Robert Ferrer, MD MPH, of the University of Texas Health Science Center at San Antonio, to come up with an alternative, more "technical", response to the "technical" question:

The problem with consumer-directed spending is that it has the potential to curb only a small portion of health expenditures. The healthiest half of Americans accounts for only 3% of health care expenditures. Conversely, the sickest 5% account for 55% of expenditures and the sickest 10% for 70% of expenditures. So most health spending isn't folks with a cold or twisted ankle who run to the doctor. Most health spending is NICU babies and 20 year-olds with massive trauma from car accidents and cancer patients and old folks with congestive heart failure and 5 hospitalizations in the last year. None of those is engaging in discretionary spending or likely to "value shop" for health care or to direct their own spending.

I think the reason that consumer-directed spending has gained so much traction is that the vast majority of our policy wonks and lawmakers are healthy enough (with a few Ted Kennedy exceptions) to be in the category of folks for whom health spending IS discretionary. That's the world they know.

Thanks to Dr. Ferrer for adding these clear, and usually ignored, insights to the discussion

Wednesday, May 6, 2009

Health Care Thought Experiments: Mile Long Questions Traveling at the Speed of Light

This piece was written by Donald Frey, MD, Professor and Chair of the Department of Family Medicine at Creighton University in Omaha, NE. I think his point is very well made, and may help us in figuring out how to respond to the over-technical questions we sometimes get.
Dr. Frey has previously contributed to this blog, Medicare Costs in Rural America: A case of reaping what we haven't sown?, March 26, 2009.

Recently, I had the privilege of giving the Keynote Address to the annual meeting of the Nebraska Academy of Sciences. To say this was a highly improbable event is an understatement. Although I enjoyed science, and wound up majoring in chemistry, I was never someone who lived to go to the lab every afternoon. In fact, coming from a small rural community where the majority of my classmates didn’t even attend college, my initial year after high school was difficult (I still have nightmares about calculus). I never dreamed that one day I would address a group of scientists.
The group was concerned about health care cost and access, and had asked me to speak about current reform approaches. As with most presentations I make to public groups, I described the high costs of care, as well as our dismal outcomes here in the U.S., and then discussed various reform proposals. Finally, I underscored the reasons why I felt that a single payer approach was the most reasonable choice, given the body of evidence that has been accumulated with respect to costs and outcomes. Then I asked for questions.
Several hands were raised, but one gentleman at the front of the room nearly leapt out of his seat as his hand shot into the air. I called on him first.
“First of all, I don’t believe what you’ve said,” the man began. Immediately I felt dejected. Weren’t these supposed to be scientists, the people who had to contend on a regular basis with those who chose to ignore evidence and “not believe” in evolution? If you can’t convince a scientist to look at evidence with respect to single payer, I thought, who can you convince?
The man continued, “I’d like to propose a Thought Experiment.” Now I was really worried. Thought Experiments. This guy had to be a physicist.
Thought Experiments. When Einstein and Bohr would debate the merits of relativity and quantum theory, they would often do so through Thought Experiments; experiments so difficult they could only be carried out in the mind, because the testing components didn’t exist. My favorite was the one about what changes might occur in the dimensions of a mile long space ship travelling at the speed of light.
This was going to be interesting. I nodded at the gentleman, and he continued. “Let’s say we were to pay for homeowner’s insurance the way we pay for health insurance. What would it look like? How could we afford it? What if every minor repair we wanted to make on a house was covered by some sort of single payer home owner’s insurance, every minor addition? How could we afford that?”
I tried to sound as scientific as possible. “Before we can proceed with the experiment, we must challenge its assumption,” I said. “Your experiment assumes that all insurances are interchangeable. They are not. Insuring your health is not the same as insuring your home, your car, or your RV. Much more is at stake when we are talking about health.”
The physicist was not deterred. “But I think you know where I’m coming from.” (Actually, I didn’t). “Insurance by its very nature is meant to insure against catastrophic events. Your home is severely damaged. You get a severe illness. Your insurance should cover that. But routine expenses should be paid out of pocket. You shop around for the best prices for basic home repairs. But that doesn’t happen in health care. Consumers should be empowered in health care just like they are in the rest of the market place, with price data. Then they should make their own decisions.”
So that’s where your coming from, I thought. A Consumer-Directed Health Care advocate. “The problem with what you are proposing is that the decision making that confronts the health care consumer is much more complex than in home repair,” I said. “That’s why people go to doctors. If you thought you might be seriously ill, would you really ignore the doctor’s advice and just shop around?”
“But you’re ignoring the basic issue here,” the physicist shot back. “Let’s say I wanted to build a deck on my house, and I evaluate the cost. Now if I decide not to build that deck—“
At this point, I ignored what my Mother had always taught me—never interrupt someone in mid-sentence. “If you decide not to build that deck,” I interjected, “you’re not going to die.”
The physicist looked stunned. “Well—well—if I don’t do what the doctor says, I may not die, either,” he stammered.
“No,” I responded as calmly as I could, “you may not die. Instead, you might wind up on a ventilator in an ICU for several weeks because of complications from a delayed diagnosis. You exhaust your insurance benefits, then deplete your savings. You have no way to pay for your care. But this being a just society,” (I smiled at the irony) “you won’t be kicked out into the street. And then what happens to your costs?” I looked out at the rest of the audience. “They will be shifted to everyone else in this room through higher premiums and charges.
“So the cost of your consumer-based decision not to follow your doctor’s advice, unlike a decision not to build a deck, won’t just affect you. It will have a significant economic impact on everyone else, too.” I turned back to the questioning physicist, to give him a chance to reply. Instead, he simply glared at me.
I turned back to the rest of the audience. “So what have we learned from this Thought Experiment? First, that health care is so unique, with such enormous economic risk for all of us, that to ‘insure’ it really falls into a different category than any other form of insurance. It’s different than insuring our homes. Consequently, if we approach health insurance from the standpoint of it being just another form of insurance, following the same rules as every other form of insurance, we set ourselves up for a failed system of delivery.
“In that sense,” I concluded, “maybe we shouldn’t even talk about health ‘insurance’ because it detracts from the critical nature of what confronts us. Perhaps we need to be talking about health care access as a part of our national economic infrastructure, like roads and highways—an item too vital to simply be thrown into the general category of insurance.” Around the room, heads nodded.
I wish I could have spoken to the physicist privately after the lecture, but he rose from his seat, turned, and quickly strode from the room. But the experience stayed with me as I reflected on the challenge that faces all of us as we carry the message of the critical importance of universal health care. It reminded me once again how many opponents will use tactics such as shifting the discussion away from health care itself, to more arcane issues such as the nature of insurance. It underscored the importance of promoting the value of health care, first and foremost, in any discussion of policy change.
Finally, it was one more reminder that questions about single payer health care must be answered one question at a time, and one citizen at a time. For many Americans, the amount of misinformation regarding universal health care is staggering, and those of us committed to reform must use every tool at our disposal to see that the truth gets out there.
Even if it means sometimes speaking in terms of mile long space ships travelling at the speed of light.

Saturday, May 2, 2009

Health disadvantages of Americans compared to Europeans

I have written often about the absurd non-system of health care and health insurance that exists in the United States, and unabashedly argued for (and, I hope, supported these arguments with data) a single-payer health system such as that that exists in Canada. I have also addressed the inequities that this creates for our people, with great disparities in health outcomes between the rich and poor and between the insured and uninsured. I have cited studies and other data that shows that, despite spending more than twice as much as any other developed country on health care, our outcomes are worse – our infant mortality and maternal mortality rates, our life expectancy, our years of productive life lost and disability-adjusted life expectancy, along with virtually every other measure.

The March 2009 issue of the American Journal of Public Health contains an article by a group from the Netherlands entitled “Health disadvantage in US adults aged 50 to 74 years: A comparison of the health of rich and poor Americans with that of Europeans”.[1] The goal of the study was to look at the health differences that exist between Americans and Europeans and assess whether wealth is a factor in those differences, and whether there are differences in Europe as well. In other words, it looked at both the difference in health between wealthy and poorer Americans and Europeans (comparing “tertiles”, top, middle and bottom thirds of wealth within each country, to minimize the impact of differences in wealth between countries) as well as the overall difference between Americans and Europeans. The study examined 9,900 Americans aged 50-74 and compared them to 6,500 English and 17,000 mainland Europeans of the same age range. To exclude the effect of racial disparities (why? see my comment below), only non-Latino white US adults were included in the study.

The results?

1. The rate every disease examined was higher in the US adults than in either the English or European groups.
Rates of cancer in the US were 11%, while 6% in England and 5% in Europe. Heart disease rates were 18% in the US, 12% in Britain, and 11% in Europe.
2. In all groups the rate of disease was higher in the poorer than in the wealthier groups. Except for cancer, apparently an equal-opportunity disease
3. The difference between rich and poor were much greater in the US and England than in Europe.
Example: Risk of stroke of poorest third of Americans compared to richest was 1.9; in England 2.08 (not a significant difference) but in Europe 1.36; for heart disease the numbers were 1.94 for the US, 2.13 for England and 1.38 for Europe.

The exclusion of all but non-Latino whites from the US sample is hard to justify because 1) these people are Americans and the explanation often heard that it is minorities who have poorer health as if this was an excuse or OK, and 2) the growing numbers of racial minorities in Europe were not excluded. Amazingly, however, even with this exclusion, health was much worse in the US. Including all Americans, the non-white and Latino who in fact often are on the “short end” of health disparities, would make the differences even greater!

And what about the fact that the wealth/class differences in England are at least as great as in the US? In part of this can be explained by the fact that, although they have a National Health Service it was until recently very underfunded (remember, there is a difference between how much money is spent per capita and how it is distributed) and that wealthier Britons can “buy out” and purchase private care. However, it is important to note the context: while the odds of having heart disease in the poorest vs the richest third in England was 2.13, slightly more than the 1.94 in the US, the overall rate of heart disease was only 2/3 of that in the US (12% vs 18%), thus all English groups are doing significantly better than their US counterparts.

What will it take to convince Americans that we do NOT have the “best health care system in the world”? At best, many Americans get the best health care available much of the time (and even the most privileged often suffer from getting too much care), many others get less than the best care, and yet others get almost none. As far as “system”, we have none; it is, in Ferrer’s words a “non-system”.[2] The data is clear, consistent, replicable, and unimpeachable. Virtually all other first-world countries with health systems and universal coverage (whether from single-payer, national health service, or highly regulated non-profit insurance companies) have far better health outcomes for their people at far lower cost.

We can no longer plead ignorance of the facts (although the ignorance of many of our leaders, willful or otherwise, should not be disregarded). Our policies, our insistence on having a bad system (or non-system) that spends huge amounts of money with poor outcomes and our resistance to a change that will improve both, represents either an ideological commitment to bad ideas, or complete corruption in selling out to those insurance companies, pharmaceutical and device makers, and providers who pocket the huge amount of money we call “health care expenditures” but are really a gift of profit from us all at the expense of our health.

[1] Avedano M, MM Glymour, J Banks, J Mackenbach, “Health disadvantage in US adults aged 50 to 74 years: A comparison of the health of rich and poor Americans with that of Europeans”, Am J Pub Health Mar09; 99(3):540
[2] Ferrer RL, “Within the system of no-system”, JAMA 2001;286:2513-14

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