.
Sen. Lamar Alexander of Tennessee, chosen to be the Republican “point man” at President Obama’s health care summit presumably because he doesn’t come off like the meanest scold in the school the way Minority Leader Mitch McConnell of Kentucky does, told us afterwards that while his party supported almost nothing in the President’s health care proposal (including those aspects that they formerly championed) they had “better ideas”. This is a good thing, since they have no policy proposal. Those ideas being not on display at the meeting, where they spent their time sniping at the President’s proposal, I went to the Op-Ed in New York Times of February 22, 2010 where 5 prominent Republicans not currently in Congress discussed “How the G.O.P. Can Fix Health Care”.
Some of these are not bad ideas at all. Bill Frist, a heart transplant surgeon and former Senate Majority Leader (when the Republicans controlled both houses of Congress and the Presidency and did not do health care reform), although he cannot resist saying that the power to change is “…just not in the Democratic leaders’ DNA,” because they oppose markets, tells us that “Transforming health care to slow the growth of spending requires a radical restructuring of how health services are paid for. . The most powerful way to reduce costs (and make room to expand coverage) is to shift away from ‘volume-based’ reimbursement (the more you do, the more money you make) to 'value-based' reimbursement.” I agree and think I am on record as advocating that. “Reward value, not volume,” he says, “Medicare and private insurance companies should reimburse providers not for each discrete service they provide but for managing a patient’s condition over an entire episode of care… Health care providers could then compete on the basis of efficiency and success.” He also says, demonstrating more faith than evidence based on past performance, that at the local level waste would “most likely” be eliminated, and that “markets work”. It is a shame that Frist didn’t try to implement any of these changes when he had so much power. He also addresses not at all the other major issue of health reform, which is providing access to care for the poor, uninsured, and underinsured. Maybe not surprising from one who is not only a super-subspecialist doctor but a member of the family that created and owns Hospital Corporation of America (HCA), a huge for-profit chain that has never concerned itself about caring for the underserved.
Mark McClellan, the former head of the Center for Medicare and Medicaid Services (CMS) under President Bush, and now at the Brookings Institution, also has suggestions for saving money, though not as radical as Dr. Frist’s, and also completely avoids the coverage of those who are currently unable to access adequate health care. James Pinkerton, of the New America Foundation and a former advisor to Presidents Reagan and GHW Bush, does begin to address health care, not just money. He says Americans want more medical care but that they should also be able to get better health. I’m all for the better health part, but am not convinced by any evidence that more medical care overall is needed, though certainly some people need more than they are getting. Unfortunately, Pinkerton’s piece is entirely platitudes; while he doesn’t say he thinks we need more medical care, he offers no suggestions that would lead to better health, or (surprise!) even mention the problem of how to cover the uninsured. Another former policy advisor to President GHW Bush and president of the “nonpartisan” Committee for Economic Development, Charles Kolb, begins to get to the issue of coverage, saying both Medicare and the current private insurance market don’t work and we need a plan like the one for federal employees to compete with private insurance companies. He actually mentions the word “uninsured” and tells us that the way to fund coverage for them is to eliminate the tax deduction for employer based health care contributions. This might help but there would require a lot of other money. And this one will increase the costs to those already insured, as businesses will pass them on to their employees.
Finally, we have the distinguished Newt Gingrich, the former Speaker of the House whose caucus derailed President Clinton’s efforts at health care reform, as well as every other progressive idea that might help the American people, while posturing as a social conservative family-values guy and leaving his wife – who had cancer – for another woman. Not the first, but certainly not the last of incredible hypocrites wearing the Republican colors. And yes, I know about Eliot Spitzer, but you can’t beat the Republicans for sanctimonious words that are violated by their actions. (Kind of like all the GW Bush “hawks” from Cheney on down who never served in the military but were willing to paint as soft those who had, not only Al Gore but John Kerry and Max Cleland, who lost two legs and an arm in Vietnam, for goodness sakes!) Anyway, Newt is also against wasteful spending, and tells us that we can save $600 billion a year if we eliminate unnecessary care. This is presumably much of the same care that the majority of the people in the study cited by Charles Kolb want more of, but no matter. Gingrich is absolutely right on the need to control unnecessary care, most of it done by sub-sub-specialists (like Frist) and not primary care physicians, but how much is unclear; we do waste money, but most efforts to save Medicare from “fraud” seem to look like across-the-board witch hunts in which a set amount is to be recouped (e.g., we won’t pay for care that is a certain amount, like more than one or two standard deviations above the mean) rather than looking at the need for that care in that patient. And, of course, Gingrich doesn’t advocate using the savings for covering the uninsured, though at least he has “provided” the money. Again, something that he never did when in office, and his successors currently in office are not advocating.
So what do we have? Some reasonable ideas for saving money and controlling costs from Republicans who used to have power in government, but nothing concrete at all being offered up by those who are now in Congress. We have a virtually complete ignoring by these NY Times Op-Ed writers of the fact that there are 45 million uninsured and another 30 million underinsured in this country, a number that is growing , and that increasing large numbers of insured can’t afford it and can’t get the care that they need, while the insurance companies (see “Anthem Blue Cross of California”) are trying their best to seem as voracious and evil as the bankers and financiers who ruined the world’s economy for everyone. (And both, the financiers and the insurance companies, are making out like, well, the bandits that they are!) We have Republicans in Congress who can only oppose and snipe, and fear mainly that the Democrats, who have a large majority in both houses, may actually use it to pass a kind of (weak) health reform by using the budget reconciliation process. That part is ok; it still requires a majority and in contradiction to the conscious outright lying by the Republicans is the way most health legislation has been passed. For example, COBRA, that allows you to buy insurance coverage from your former employer when you lose your job, gets its name from the Consolidated Omnibus Budget and Reconciliation Act of 1986, SOBRA (Sixth OBRA of 1986), the State Children’s Health Insurance Program (S-CHIP) and the creation of Medicare Advantage plans (1991) – see Firedog Lake. Also both Bush tax cuts of 2001 and 2003 were implemented by Republican use of the budget reconciliation process.
And a terrible Democratic plan, that, in an apparent effort to garner either Republican or conservative Democratic support, is a huge giveaway to the insurance industry. See the great comments of Dr. Don McCanne, and the Reuters February 25, 2010 article by Drs. Steffie Woolhandler and David Himmelsten. But at least it will eliminate discrimination for pre-existing conditions and cover more people (maybe 30 million; why is covering only 30 million of the uninsured ok?). But given that the best Republican ideas don’t cover more than 3 million of the current uninsured, the answer to getting a better idea is never going to come from that side of the aisle.
A single-payer, Medicare for All, plan, would cover everyone, save a huge amount of money initially and provide the mechanism for future cost savings and controls, and is apparently off both the Democratic and Republican tables. It would “take” the money from the for-profit insurance companies who offer little value and run up our costs and wastes in an effort to make their profits. Call the President and your Senators and Congressman and demand single payer. Every day.
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Saturday, February 27, 2010
Thursday, February 18, 2010
Poverty, Primary Care and the Cost of Medical Care
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On January 27, 2010 (Health is more than Medical Care) I discussed how the concept in the title of that piece is true. A society that does not provide for the basic needs of its citizens, such as the US, is going to have more sick poor people who end up requiring more health care services at much greater cost. The greater the income disparity in a country, the greater the negative impact of poor population health. Countries that have a national health system can mitigate some of these effects by, at least, providing access to care for those who, through the various negative effects of poverty, suffer the worst health, but they do not prevent it.
This point is illustrated in the latest (of many, over the years and decades) reports on health status in the United Kingdom, commissioned by the government and done by a panel headed by Sir Michael Marmot of the University College – London. The report, “Fair Society, Healthy Lives”, documents the cost to the National Health Service of the ill health of the poor. This is not, of course, news; Marmot’s famous Whitehall studies demonstrate that there is a more or less linear correlation between health (including longevity) and increasing social class; it shows that the problems have not been resolved. In countries with less disparity of wealth and income (class) than the UK, including most of Scandinavia, these disparities in health are less; in the US, where the disparities in wealth and income are greater, so are the disparities in health and their associated cost.
Since, in the US, poor people are more likely to be uninsured (or have Medicare, if they are over 65), their health care costs are largely borne by the public sector. In this sense, the costs of Medicare can, and have, been used as markers for the overall cost of medical care. This assumption has a great deal of validity, because Medicare recipients, the “aged, blind, and disabled”, are highly overrepresented in both the middle and high use segments of the population (see Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009). (It is, however, important to remember that the majority of the 5% of “highest cost” users are not seniors – they include NICU babies, multiple trauma victims, and cancer patients.) The publications of the Dartmouth Atlas of Health Care have demonstrated much geographic variation in cost, and these have been used by a large number of health economist and scholars, as well as the Obama administration, to suggest that a great deal of health spending could be avoided if the “high cost” regions utilized health resources at the same rate as the lower cost areas.
Not everyone agrees with the Dartmouth analysis. Probably their most prominent critic is Dr. Richard Cooper of the University of Pennsylvania’s Wharton School, whose positions I have previously discussed on several occasions (most recently January 7, 2010, Primary Care and Residency Expansion). On his blog, Physicians and Health Care Reform, and in venues such as the on-line public health discussion group “Spirit of 1848”, Dr. Cooper argues that it is poverty rather than “inappropriate” use of health services that drive the differences in Medicare spending in different regions. He illustrates this by maps showing the far greater density of poverty in “high cost” Los Angeles, Miami, and Birmingham, AL compared to “low cost” Rochester, MN, Grand Junction, CO, and Portland, OR.
Many others disagree with Dr. Cooper, not in the sense that they feel that poverty is not a (or the) major determinant of health status, but with his assertion that the cost variations the Dartmouth Atlas identifies are solely an artifact based on prevalence of poverty. Among the most prominent of these critics is Dr. Barbara Starfield, of the Johns Hopkins University, a major health services researcher whom I have also often cited. I believe that Cooper’s argument that the Upper Midwest is richer, and thus healthier, than the Southeast is relying on areas that are too large. His contrasts of the cities above in terms of their concentrations of poverty are accurate, but the argument misses the tremendous difference (cited by Dr. Atul Gawande in his piece “The Cost Conundrum” and its followup “The Cost Conundrum Redux” in the New Yorker) between cities such as McAllen and El Paso, TX. Or, for that matter, between Los Angeles and San Francisco, or Chicago, all of which have varying levels of health costs (i.e., Medicare spending).
The real issue is “what is the implication of either position, or any other, for what to do to address the health needs, and cost of medical care, for the US population?” From much of his previous writing, Dr. Cooper has disparaged the contribution of primary care prevalence to the quality of health care, seeing it as a confounder to the true cause of higher spending, because it is more prevalent in the Upper Midwest than in the high cost areas. The data, from many, many studies in many, many countries, not only those by Starfield and the Dartmouth folks, is that it is not a confounder. Where health systems are built on primary care costs are lower and, more important, quality is higher. This should not be a surprise to anyone who is concerned about the impact of poverty on health status – when poor people can access preventive services and treatment at an earlier stage, where intervention is both less costly and more effective, they will have better health status. Primary care reduces cost.
Hospitals and many subspecialist physicians are not happy about the potential for cuts in Medicare because they already think that Medicare spends too little. That is, it does not pay “enough” for the extraordinarily costly high-tech interventions that they make their profit on. I suggest that Medicare spends too much on this kind of care, rather than paying a lot more for the preventive and primary care services that would make this kind of tertiary intervention necessary less often. Medicare should not simply make revisions to its payment schedule, it should completely turn it on its head so that a day of managing multiple complex medical and social problems and doing preventive care by a primary care doctor generates more money than a day of doing procedures such as endoscopies, catheterizations, and the like. (Note that I am not suggesting we invert the incomes, just the amount that these doctors earn relative to each other; the net cost should be dramatically reduced.)
This would, of course, encourage more medical students to enter primary care, which would be a good thing for the health of us all. Simply increasing the number of funded-by-Medicare residency positions will not do that, but rather would just generate more hoping-for-high-income sub- and sub-subspecialists, whose overall effect on health status is, from a population perspective, small. (For example, I benefit, for sure, if my brain tumor is excised or my cerebral bleed drained, and I definitely want access to its benefit, for me and you and the poor; however, if there were no neurosurgery at all, the impact on the health status of populations would be minimal.)
More important, it would free up a lot more money for addressing the overall social problems of poverty, while now the cost of medical care, exceeding 17.3% of the GDP (CMS report by Truffer CJ, et al, in Health Affairs, February 4, 2010) threatens to choke off any other social spending. As articulately stated by Bob Phillips of the Graham Center (personal communication), giving the “…poor the same access to excess that all of the rest of us have in order to lift them from disparity would only hurt them more. Economically, health care is starving the services that do help reduce disparities--education, social services, day care, Head Start, food stamps, etc. They are all suffering right now in state budgets because healthcare is devouring state budgets (health care consumed 1/3rd of all f
ed/state tax dollar s in 2008,[1] (and probably more now that tax revenue is down)”. This is demonstrated by the 2005 study by Boston University’s Sager and Socolar[2] and shown in the attached graphic, from the Graham Center’s presentation on the topic. Obviously, there would still need to be a decision by our society to spend the savings on social services (rather than, say, tax rebates to the wealthiest Americans, or war), but, other than war, there is hardly a less useful way to improve the health status of the poor than by spending it on more high cost tertiary and quarternary care medical centers staffed by more and more sub-sub-specialists.
[1] Sessions S and Lee PR,”Using Tax Reform to Drive Health Care Reform: Putting the Horse Before the Cart” JAMA. 2008;300(16):1929-1931
[2] Sager A, Socolar D, Health Costs Absorb One-Quarter of Economic Growth, 2000 – 2005 Recent Federal Report Unintentionally Obscures Massive Rise Physicians’ Decisions Key to Controlling Cost. Data Brief No. 8 - 9 February 2005. http://www.healthreformprogram.org/.
On January 27, 2010 (Health is more than Medical Care) I discussed how the concept in the title of that piece is true. A society that does not provide for the basic needs of its citizens, such as the US, is going to have more sick poor people who end up requiring more health care services at much greater cost. The greater the income disparity in a country, the greater the negative impact of poor population health. Countries that have a national health system can mitigate some of these effects by, at least, providing access to care for those who, through the various negative effects of poverty, suffer the worst health, but they do not prevent it.
This point is illustrated in the latest (of many, over the years and decades) reports on health status in the United Kingdom, commissioned by the government and done by a panel headed by Sir Michael Marmot of the University College – London. The report, “Fair Society, Healthy Lives”, documents the cost to the National Health Service of the ill health of the poor. This is not, of course, news; Marmot’s famous Whitehall studies demonstrate that there is a more or less linear correlation between health (including longevity) and increasing social class; it shows that the problems have not been resolved. In countries with less disparity of wealth and income (class) than the UK, including most of Scandinavia, these disparities in health are less; in the US, where the disparities in wealth and income are greater, so are the disparities in health and their associated cost.
Since, in the US, poor people are more likely to be uninsured (or have Medicare, if they are over 65), their health care costs are largely borne by the public sector. In this sense, the costs of Medicare can, and have, been used as markers for the overall cost of medical care. This assumption has a great deal of validity, because Medicare recipients, the “aged, blind, and disabled”, are highly overrepresented in both the middle and high use segments of the population (see Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009). (It is, however, important to remember that the majority of the 5% of “highest cost” users are not seniors – they include NICU babies, multiple trauma victims, and cancer patients.) The publications of the Dartmouth Atlas of Health Care have demonstrated much geographic variation in cost, and these have been used by a large number of health economist and scholars, as well as the Obama administration, to suggest that a great deal of health spending could be avoided if the “high cost” regions utilized health resources at the same rate as the lower cost areas.
Not everyone agrees with the Dartmouth analysis. Probably their most prominent critic is Dr. Richard Cooper of the University of Pennsylvania’s Wharton School, whose positions I have previously discussed on several occasions (most recently January 7, 2010, Primary Care and Residency Expansion). On his blog, Physicians and Health Care Reform, and in venues such as the on-line public health discussion group “Spirit of 1848”, Dr. Cooper argues that it is poverty rather than “inappropriate” use of health services that drive the differences in Medicare spending in different regions. He illustrates this by maps showing the far greater density of poverty in “high cost” Los Angeles, Miami, and Birmingham, AL compared to “low cost” Rochester, MN, Grand Junction, CO, and Portland, OR.
Many others disagree with Dr. Cooper, not in the sense that they feel that poverty is not a (or the) major determinant of health status, but with his assertion that the cost variations the Dartmouth Atlas identifies are solely an artifact based on prevalence of poverty. Among the most prominent of these critics is Dr. Barbara Starfield, of the Johns Hopkins University, a major health services researcher whom I have also often cited. I believe that Cooper’s argument that the Upper Midwest is richer, and thus healthier, than the Southeast is relying on areas that are too large. His contrasts of the cities above in terms of their concentrations of poverty are accurate, but the argument misses the tremendous difference (cited by Dr. Atul Gawande in his piece “The Cost Conundrum” and its followup “The Cost Conundrum Redux” in the New Yorker) between cities such as McAllen and El Paso, TX. Or, for that matter, between Los Angeles and San Francisco, or Chicago, all of which have varying levels of health costs (i.e., Medicare spending).
The real issue is “what is the implication of either position, or any other, for what to do to address the health needs, and cost of medical care, for the US population?” From much of his previous writing, Dr. Cooper has disparaged the contribution of primary care prevalence to the quality of health care, seeing it as a confounder to the true cause of higher spending, because it is more prevalent in the Upper Midwest than in the high cost areas. The data, from many, many studies in many, many countries, not only those by Starfield and the Dartmouth folks, is that it is not a confounder. Where health systems are built on primary care costs are lower and, more important, quality is higher. This should not be a surprise to anyone who is concerned about the impact of poverty on health status – when poor people can access preventive services and treatment at an earlier stage, where intervention is both less costly and more effective, they will have better health status. Primary care reduces cost.
Hospitals and many subspecialist physicians are not happy about the potential for cuts in Medicare because they already think that Medicare spends too little. That is, it does not pay “enough” for the extraordinarily costly high-tech interventions that they make their profit on. I suggest that Medicare spends too much on this kind of care, rather than paying a lot more for the preventive and primary care services that would make this kind of tertiary intervention necessary less often. Medicare should not simply make revisions to its payment schedule, it should completely turn it on its head so that a day of managing multiple complex medical and social problems and doing preventive care by a primary care doctor generates more money than a day of doing procedures such as endoscopies, catheterizations, and the like. (Note that I am not suggesting we invert the incomes, just the amount that these doctors earn relative to each other; the net cost should be dramatically reduced.)
This would, of course, encourage more medical students to enter primary care, which would be a good thing for the health of us all. Simply increasing the number of funded-by-Medicare residency positions will not do that, but rather would just generate more hoping-for-high-income sub- and sub-subspecialists, whose overall effect on health status is, from a population perspective, small. (For example, I benefit, for sure, if my brain tumor is excised or my cerebral bleed drained, and I definitely want access to its benefit, for me and you and the poor; however, if there were no neurosurgery at all, the impact on the health status of populations would be minimal.)
More important, it would free up a lot more money for addressing the overall social problems of poverty, while now the cost of medical care, exceeding 17.3% of the GDP (CMS report by Truffer CJ, et al, in Health Affairs, February 4, 2010) threatens to choke off any other social spending. As articulately stated by Bob Phillips of the Graham Center (personal communication), giving the “…poor the same access to excess that all of the rest of us have in order to lift them from disparity would only hurt them more. Economically, health care is starving the services that do help reduce disparities--education, social services, day care, Head Start, food stamps, etc. They are all suffering right now in state budgets because healthcare is devouring state budgets (health care consumed 1/3rd of all f
ed/state tax dollar s in 2008,[1] (and probably more now that tax revenue is down)”. This is demonstrated by the 2005 study by Boston University’s Sager and Socolar[2] and shown in the attached graphic, from the Graham Center’s presentation on the topic. Obviously, there would still need to be a decision by our society to spend the savings on social services (rather than, say, tax rebates to the wealthiest Americans, or war), but, other than war, there is hardly a less useful way to improve the health status of the poor than by spending it on more high cost tertiary and quarternary care medical centers staffed by more and more sub-sub-specialists.[1] Sessions S and Lee PR,”Using Tax Reform to Drive Health Care Reform: Putting the Horse Before the Cart” JAMA. 2008;300(16):1929-1931
[2] Sager A, Socolar D, Health Costs Absorb One-Quarter of Economic Growth, 2000 – 2005 Recent Federal Report Unintentionally Obscures Massive Rise Physicians’ Decisions Key to Controlling Cost. Data Brief No. 8 - 9 February 2005. http://www.healthreformprogram.org/.
Monday, February 15, 2010
Correction to the Meyers, et al paper on smoking bans
The paper by Meyers, et. al., cited in the February 6, 2010 blog, had a correction issued in the Journal of the American College of Cardiology, which had to do with a statistical calculation error. The association between smoking bans and decrease in AMI (heart attack) is still strong but less so; the rate goes down 14%, not 26%, per year after bans are in place
The formal correction published in JACC is:
Meyers DG, Neuberger JS, He J. Cardiovascular Effect of Bans on Smoking in Public Places: A Systematic Review and Meta-Analysis. J Am Coll Cardiol 2009;54:1249 –55.
In this article, the meta-analysis included data from Pueblo, Colorado, which the authors erroneously reported as incidence rate ratio (IRR): 0.30. Actually, the IRR is 0.66 (95% confidence interval [CI]: 0.58 to 0.75). This changes the meta-analysis summary IRR to 0.92 (95% CI: 0.86 to 0.99). The meta-regression of the effect of ban duration also changes. The coefficient of post-ban duration in the meta-regression model is -0.16 (95% CI: -0.20 to-0.11), meaning that the IRR decreases by 14% (95% CI: 11% to 18%) for each year of post-ban observation (e.g., IRR: 0.86 after 1 year, then 0.73, then 0.63 compared with pre-ban).
The authors regret this error.
The formal correction published in JACC is:
Meyers DG, Neuberger JS, He J. Cardiovascular Effect of Bans on Smoking in Public Places: A Systematic Review and Meta-Analysis. J Am Coll Cardiol 2009;54:1249 –55.
In this article, the meta-analysis included data from Pueblo, Colorado, which the authors erroneously reported as incidence rate ratio (IRR): 0.30. Actually, the IRR is 0.66 (95% confidence interval [CI]: 0.58 to 0.75). This changes the meta-analysis summary IRR to 0.92 (95% CI: 0.86 to 0.99). The meta-regression of the effect of ban duration also changes. The coefficient of post-ban duration in the meta-regression model is -0.16 (95% CI: -0.20 to-0.11), meaning that the IRR decreases by 14% (95% CI: 11% to 18%) for each year of post-ban observation (e.g., IRR: 0.86 after 1 year, then 0.73, then 0.63 compared with pre-ban).
The authors regret this error.
Saturday, February 13, 2010
Insurance company greed: To know them is to not trust them
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Anthem Blue Cross, a subsidiary of WellPoint of Indianapolis, has taken a lot of criticism for its proposed rate increases on its 800,000 individual policies in California (“Anthem Blue Cross dramatically raising rates for Californians with individual health policies”, Duke Helfand in the Los Angeles Times February 4, 2010, http://www.latimes.com/business/la-fi-insure-anthem5-2010feb05,0,3002094.story), to the extent that a follow-up article by Helfand on February 12 (“Anthem's parent company defends health insurance rate hike”, http://www.latimes.com/business/la-fi-anthem12-2010feb12,0,3807841.story) calls them “beleaguered”. They deserve to be. Their action is not only outrageous, it points out the absolute absurdity of thinking that a solution to the nation’s health care access problems can involve for-profit insurance companies.
Anthem announced increases of up to 39% on individual policies, but the WellPoint announcement adds insult to injury when it says “…that less than a quarter of affected Anthem customers in California will see rate increases of 35% to 39%. The average will be about 25%, while some customers will see rates fall…” Whew! Only 25% on average! Only a quarter of those affected will see increases in the 35-39% range. I guess those folks – and the rest of us because, as I will keep saying, we are all in this together! – can now rest easy.
In addition to investigations by the California Insurance Commissioner and possibly the Attorney General of the state, this one outrageous act has been the target of increasing criticism from the administration and from Congress. Rep. Henry Waxman, Chair of the Energy and Commerce Committee, announced hearings into the rate increase (http://www.speaker.gov/blog/?p=2149), and HHS Secretary Kathleen Sebelius is quoted by Helfand as saying “It remains difficult to understand how a company that made $2.7 billion in the last quarter of 2009 alone can justify massive increases that will leave consumers with nothing but bad options.” Sebelius, who is absolutely correct, has a history with Anthem. In 2002, as Kansas’ Insurance Commissioner, she blocked sale of Blue Cross/Blue Shield of Kansas to Anthem because it was ”not in the interest of Kansans”, an extremely popular position with both the medical and hospital societies and with the public, and played a significant role in her election as Governor later that year.
It would be a mistake, however, to see the WellPoint/Anthem action as an isolated case of stupendous greed by one insurance company. It is an example of the widespread stupendous greed of all of the health insurance companies. The New York Times’ Katharine Q. Seeley (“Administration Rejects Health Insurer’s Defense of Huge Rate Increases”, http://www.nytimes.com/2010/02/12/health/policy/12insure.html) also quotes Sebelius, but also notes that the top 5 health insurance companies, WellPoint, Cigna, UnitedHealth Group Inc., Aetna Inc. and Humana Inc., “…had an average profit last year of 5.2 percent — for a combined total of $12.2 billion. This was an increase of $4.4 billion, or 56 percent, compared with 2008…” The data comes from Security and Exchange Commission filings, and is contained in a report by “Health Care for American Now” (http://www.healthcareforamericanow.org/). The report, at http://hcfan.3cdn.net/a9ce29d3038ef8a1e1_dhm6b9q0l.pdf, also notes that the “medical loss ratio” for these companies is incredibly low. As a reminder for regular people, the ones who pay the bills, the “medical loss ratio” is the percent of the premiums insurance companies collect that they actually have to spend on providing health care, that is, that they do not get to keep!
The medical loss ratios for these companies for 2009, notes Don McCanne in his wonderful “Quote of the Day” for February 12, were:
· WellPoint - 82.6%
· UnitedHealth - 82.3%
· Humana - 82.8%
· Cigna - 81.2%
· Aetna - 85.2%
Or, “…of the estimated $809 billion spent on private health insurance in 2009, the five biggest for-profit companies... captured $232 billion.”
In case you had any illusions that these insurance companies might have made a mistake, or be embarrassed, or in any way could be thought to be serving the public, the statements of WellPoint’s spokesman, Bart Sassi, should change your minds.
"We welcome the scrutiny and are confident that our rates reflect anticipated medical costs and are established consistent with actuarial principles and state law.". That means he thinks it is legal, not that folks can afford it. He adds that Anthem's insurance policies "remain very competitively priced when compared with the dozens of other plans competing in the California individual market." Competitive with the other huge rapacious insurance companies, that is. Oligopolies don’t compete.
Helfand (Feb 11) also reports that “Anthem is not the only health insurer imposing double-digit rate increases. Competitors such as Blue Shield of California and Aetna also have raised premiums significantly in recent years, insurance brokers said. But they said the impending Anthem increases are the largest they have seen.” But at least we know that they have a human side, and are empathic. "We care deeply about our California customers and community,"Sassi said, "Clearly, we understand that these increases create a challenge for many of our members." Not that they are going to do anything about it except raise rates. Words are cheap.
The real message here is that health care reform must happen, and that to include for-profit insurance companies as the centerpiece, or as any meaningful component, is absurd and will guarantee failure in both of its goals: meeting the health access needs of the American people and controlling costs so that medical care does not bankrupt us and prevent the society from implementing the other necessary programs essential to health. If not a government-run single payer plan (the best choice), any health reform plan that does involve insurance companies must require them to be non-profit, or at least closely regulated by the government regarding the services that they must provide and the prices that they can charge. One of these methods is used by every other developed country, all of which have better outcomes for lower cost than we do.
The physician and ethicist Howard Brody has written an important article, “Medicine’s ethical responsibility for health care reform – the top 5 list”, New England Journal of Medicine, Jan 10 2010;362(4):283-5 http://content.nejm.org.proxy.kumc.edu:2048/cgi/content/full/362/4/283, in which he calls on physicians to take a strong and concrete role in cost control by limiting the tests and procedures that they order to those which are evidence based. He suggests that each specialty, through its specialty societies, identify the “Top 5” procedures that are commonly done their field that are both costly and not evidence-based, and exert pressure on their members to refrain from doing them. Indeed, to keep. Brody’s ethical justification for calling on doctors to do this is that “Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests — including their financial interests.” He adds that, while insurance companies, along with pharmaceutical companies, have promised the President to cut their costs as a “contribution” to health reform, “None of the for-profit health care industries that have promised cost savings have taken such an oath.”
You can say that again. This latest round of premium increases to bolster their obscene profits also shows how false their promises were. From the Obama administration and its Congressional allies who have been trying to steer an impossible “middle course”, to the Republican who have united in obstructionism and whose only offering is more give-aways to the insurance industry, to the “teabagger” populists who fear big government but should fear the private insurers rapacity more, it should be clear: To know this is to not trust them.
.
Anthem Blue Cross, a subsidiary of WellPoint of Indianapolis, has taken a lot of criticism for its proposed rate increases on its 800,000 individual policies in California (“Anthem Blue Cross dramatically raising rates for Californians with individual health policies”, Duke Helfand in the Los Angeles Times February 4, 2010, http://www.latimes.com/business/la-fi-insure-anthem5-2010feb05,0,3002094.story), to the extent that a follow-up article by Helfand on February 12 (“Anthem's parent company defends health insurance rate hike”, http://www.latimes.com/business/la-fi-anthem12-2010feb12,0,3807841.story) calls them “beleaguered”. They deserve to be. Their action is not only outrageous, it points out the absolute absurdity of thinking that a solution to the nation’s health care access problems can involve for-profit insurance companies.
Anthem announced increases of up to 39% on individual policies, but the WellPoint announcement adds insult to injury when it says “…that less than a quarter of affected Anthem customers in California will see rate increases of 35% to 39%. The average will be about 25%, while some customers will see rates fall…” Whew! Only 25% on average! Only a quarter of those affected will see increases in the 35-39% range. I guess those folks – and the rest of us because, as I will keep saying, we are all in this together! – can now rest easy.
In addition to investigations by the California Insurance Commissioner and possibly the Attorney General of the state, this one outrageous act has been the target of increasing criticism from the administration and from Congress. Rep. Henry Waxman, Chair of the Energy and Commerce Committee, announced hearings into the rate increase (http://www.speaker.gov/blog/?p=2149), and HHS Secretary Kathleen Sebelius is quoted by Helfand as saying “It remains difficult to understand how a company that made $2.7 billion in the last quarter of 2009 alone can justify massive increases that will leave consumers with nothing but bad options.” Sebelius, who is absolutely correct, has a history with Anthem. In 2002, as Kansas’ Insurance Commissioner, she blocked sale of Blue Cross/Blue Shield of Kansas to Anthem because it was ”not in the interest of Kansans”, an extremely popular position with both the medical and hospital societies and with the public, and played a significant role in her election as Governor later that year.
It would be a mistake, however, to see the WellPoint/Anthem action as an isolated case of stupendous greed by one insurance company. It is an example of the widespread stupendous greed of all of the health insurance companies. The New York Times’ Katharine Q. Seeley (“Administration Rejects Health Insurer’s Defense of Huge Rate Increases”, http://www.nytimes.com/2010/02/12/health/policy/12insure.html) also quotes Sebelius, but also notes that the top 5 health insurance companies, WellPoint, Cigna, UnitedHealth Group Inc., Aetna Inc. and Humana Inc., “…had an average profit last year of 5.2 percent — for a combined total of $12.2 billion. This was an increase of $4.4 billion, or 56 percent, compared with 2008…” The data comes from Security and Exchange Commission filings, and is contained in a report by “Health Care for American Now” (http://www.healthcareforamericanow.org/). The report, at http://hcfan.3cdn.net/a9ce29d3038ef8a1e1_dhm6b9q0l.pdf, also notes that the “medical loss ratio” for these companies is incredibly low. As a reminder for regular people, the ones who pay the bills, the “medical loss ratio” is the percent of the premiums insurance companies collect that they actually have to spend on providing health care, that is, that they do not get to keep!
The medical loss ratios for these companies for 2009, notes Don McCanne in his wonderful “Quote of the Day” for February 12, were:
· WellPoint - 82.6%
· UnitedHealth - 82.3%
· Humana - 82.8%
· Cigna - 81.2%
· Aetna - 85.2%
Or, “…of the estimated $809 billion spent on private health insurance in 2009, the five biggest for-profit companies... captured $232 billion.”
In case you had any illusions that these insurance companies might have made a mistake, or be embarrassed, or in any way could be thought to be serving the public, the statements of WellPoint’s spokesman, Bart Sassi, should change your minds.
"We welcome the scrutiny and are confident that our rates reflect anticipated medical costs and are established consistent with actuarial principles and state law.". That means he thinks it is legal, not that folks can afford it. He adds that Anthem's insurance policies "remain very competitively priced when compared with the dozens of other plans competing in the California individual market." Competitive with the other huge rapacious insurance companies, that is. Oligopolies don’t compete.
Helfand (Feb 11) also reports that “Anthem is not the only health insurer imposing double-digit rate increases. Competitors such as Blue Shield of California and Aetna also have raised premiums significantly in recent years, insurance brokers said. But they said the impending Anthem increases are the largest they have seen.” But at least we know that they have a human side, and are empathic. "We care deeply about our California customers and community,"Sassi said, "Clearly, we understand that these increases create a challenge for many of our members." Not that they are going to do anything about it except raise rates. Words are cheap.
The real message here is that health care reform must happen, and that to include for-profit insurance companies as the centerpiece, or as any meaningful component, is absurd and will guarantee failure in both of its goals: meeting the health access needs of the American people and controlling costs so that medical care does not bankrupt us and prevent the society from implementing the other necessary programs essential to health. If not a government-run single payer plan (the best choice), any health reform plan that does involve insurance companies must require them to be non-profit, or at least closely regulated by the government regarding the services that they must provide and the prices that they can charge. One of these methods is used by every other developed country, all of which have better outcomes for lower cost than we do.
The physician and ethicist Howard Brody has written an important article, “Medicine’s ethical responsibility for health care reform – the top 5 list”, New England Journal of Medicine, Jan 10 2010;362(4):283-5 http://content.nejm.org.proxy.kumc.edu:2048/cgi/content/full/362/4/283, in which he calls on physicians to take a strong and concrete role in cost control by limiting the tests and procedures that they order to those which are evidence based. He suggests that each specialty, through its specialty societies, identify the “Top 5” procedures that are commonly done their field that are both costly and not evidence-based, and exert pressure on their members to refrain from doing them. Indeed, to keep. Brody’s ethical justification for calling on doctors to do this is that “Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests — including their financial interests.” He adds that, while insurance companies, along with pharmaceutical companies, have promised the President to cut their costs as a “contribution” to health reform, “None of the for-profit health care industries that have promised cost savings have taken such an oath.”
You can say that again. This latest round of premium increases to bolster their obscene profits also shows how false their promises were. From the Obama administration and its Congressional allies who have been trying to steer an impossible “middle course”, to the Republican who have united in obstructionism and whose only offering is more give-aways to the insurance industry, to the “teabagger” populists who fear big government but should fear the private insurers rapacity more, it should be clear: To know this is to not trust them.
.
Saturday, February 6, 2010
The Public’s Health: Smoking and Salt
.
People pretty much know that smoking is bad for you. You, the smoker, and you, the person exposed to secondhand smoke. Smoking accounts for over 450,000 deaths a year in the US, more than alcohol, accidents, homicides, suicides, and illegal drugs. It is good for people’s health – both the smokers and those who are exposed to that smoke in their homes, workplaces and places of recreation – that people are smoking less; fewer people are smoking and those who do are, on average, smoking fewer cigarettes. Most of the people who have quit have done it on their own, rarely the first time that they tried (“Quitting smoking is easy,” said Mark Twain, “I’ve done it hundreds of times.”) Others have had help – from support groups, physicians, therapists, drugs.
But more important than individual efforts to change individual behavior is the positive impact public policy can have on public health. Mandatory immunizations for school, seat-belt laws, laws governing the safety of manufactured automobiles, helmet laws etc., have all had measurable and significant impact on our health. The two most common and important public policy initiatives regarding smoking are taxing tobacco and banning smoking in public places. In the January 27, 2010 JAMA, Mohammed K. Ali and Jeffrey P. Koplan look at “Promoting health through tobacco taxation”.[1] They show that increasing tobacco taxes decreases tobacco use, especially in young people, and thus the morbidity and mortality that comes from tobacco.
The beneficial effect of smoking bans is so enormous it suprises even tobacco control advocates. “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis”, published by David G. Meyers, John S. Neuberger, and Jianghua He in the Journal of the American College of Cardiology, September 29, 2009,[2] examined 11 studies of smoking bans done in 10 different locations and found that there was a 17% overall reduction in acute myocardial infarction (AMI = heart attack) when these bans were implemented, and that the risk incrementally decreased 26% for each year that the ban was in place. In Helena, MT a smoking ban instituted in June 2002 and resulted in a 40% decrease in AMI by the time the ban was suspended by a court order in December. After the ban was lifted, the AMI rate returned to baseline within 6 months. The impact on AMI is in addition to any effect on other diseases, such as cancers, which were not examined in this study (and would take many more years to have an effect). While much of this improvement in the public’s health comes from reducing the impact from second hand smoke on non-smokers, such bans also unquestionably encourage smokers, especially younger ones, to stop smoking. This is particularly true when quitting is something that the smoker had wanted and planned to do, with the smoking ban or increase in the tobacco tax acting as the “final straw”.
Ronald Bayer and Matthew Kelly, in the New England Journal of Medicine January 28, 2010 discuss “Tobacco control and free speech”[3] and look at how the courts are likely to decide on cases brought to them on tobacco control. While not, so far, opposing tobacco bans, the American Civil Liberties Union is supporting objections to limits on tobacco advertising on the basis of their restriction of free speech: “Burt Neuborne of the New York Civil Liberties Union told Congress that the proposed bans represented ‘a vote of no confidence in the capacity of ordinary Americans to judge for themselves how to react to tobacco advertising”. Bayer and Kelly cite the Posadas decision, written by former Chief Justice Rehnquist in 1986, that limited the advertising for a casino. The quote his opinion “It would surely…be a strange constitutional doctrine which would concede to the legislature the authority to totally ban a product or activity [such as gambling] but deny to the legislature the authority to forbid the stimulation of demand for the product or activity [advertising]”. I would argue that it is unreasonable to suggest that we can outlaw products (such as heroin, marijuana) or activities (gambling) but not restrict others (e.g., smoking in public places) and thus most often bans have been supported.
However, the Supreme Court is moving away from the Posadas position, Bayer and Kelly tell us, in the 2001 case of Lorillard Tobacco Company v. Reilly, and given the 2010 Citizens United decision in which the Court has made the bizarre declaration that corporations have First Amendment rights to give money directly to political candidates, it is far from certain that they would support tobacco bans, taxes, or restrictions on advertising in the future. Clearly, these justices who have previously styled themselves as “strict constructionists” looking at original intent”, have clearly demonstrated that they have no such belief, radically making new law and reading their own beliefs into the Constitution. But what is certain is that all these restrictions, without directly forbidding any adult from smoking, have a dramatic positive impact on the public’s health.
Another article in the New England Journal of Medcine, published on-line January 20, 2010, by Kristen Bibbins-Domingo, et. al., looks at the “Projected effect of dietary salt reductions on future cardiovascular disease”, and notes that reducing dietary salt by 3g per day (or about 1/3) would reduce the annual number of deaths from all causes by 44,000 to 92,000, and new cases of coronary heart disease by 60,000 to 120,000, stroke by 32,000 to 66,000 and AMI by 54,000 to 99,000. This is important, because in recent years the emphasis on salt reduction as a method of treating hypertension (high blood pressure), one of the big vehicles for these bad outcomes, has diminished with the marketing of large numbers of anti-hypertensive drugs. We, as physicians and the public, need reminders of the dramatic efficacy of this sort of dietary change.
The article does not address how that reduction might be accomplished; clearly, as with smoking, the effect could occur if people as individuals just reduce their salt intake. But the probability of this happening is again low. Programs such as labeling the salt/sodium content on foods in both grocery stores and restaurants, especially “fast-food” restaurants, have been implemented in a number of cities. Further regulation, actually requiring lowering of the amount of salt in these foods, would have an even greater impact. Unlike smoking bans, which have a great part of their effect through elimination of exposure of non-smokers to secondhand smoke, the benefit of salt restriction is mostly to the individual consumer. However, this does not mean that societal impetus for this change is not a critical part of changing people’s behavior. Indeed, as noted by Mark Doescher, Director of the Rural Health Research Center and the Center for Health Workforce Studies at the University of Washington in his comments on the important new textbook Community Based Health Interventions [4], “…environmental factors, such as safe streets, healthy food choices, and smoke-free establishments govern individual behavior.”
Experts in occupational safety have long recognized that changing individual behavior is the least effective way of increasing safety. If we want to prevent people from slipping on a factory floor and going through a plate glass window, the first choice is architectural (don’t put a plate glass window next to a shop floor where substances may be spilled that people can slip on). The second choice is engineering, or retrofitting (put a steel mesh over the window). The least effective choice is changing human behavior (telling people to be careful!). The dramatic reduction in deaths from car accidents over the last 30 years has had virtually nothing to do with people driving more safely, and everything to do with car manufacture (engines that collapse down instead of into your lap, air bags, etc., all of which were resisted by the automobile industry) and safer road construction. With regard to the health of the public, the same rules apply. Tobacco bans, tobacco taxes, and efforts to reduce salt intake by honest labeling are much more likely to have a salubrious impact than efforts to get people to change their behavior individual by individual. We need to encourage the latter, but because Doescher is correct, we must also implement the policy changes. We must no longer allow the economic benefit to special interests to continue to endanger the public’s health.
[1] Ali MK, Koplan JP, “Promoting health through tobacco taxation”, JAMA 27Jan10;303(4)357-8.
[2] Meyers DG, Neuberger JS, He J, “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis”, J Amer Coll Card 29Sep09;54(14):1249-55.
[3] Bayer R, Kelly M, “Tobacco control and free speech”, NEJM 28Jan10; 262(4):281-3.
[4] Guttmacher S, Kelly PJ, Ruiz-Janecko Y, eds., Community-based health interventions, Jossey-Bass, San Francisco, 2010.
People pretty much know that smoking is bad for you. You, the smoker, and you, the person exposed to secondhand smoke. Smoking accounts for over 450,000 deaths a year in the US, more than alcohol, accidents, homicides, suicides, and illegal drugs. It is good for people’s health – both the smokers and those who are exposed to that smoke in their homes, workplaces and places of recreation – that people are smoking less; fewer people are smoking and those who do are, on average, smoking fewer cigarettes. Most of the people who have quit have done it on their own, rarely the first time that they tried (“Quitting smoking is easy,” said Mark Twain, “I’ve done it hundreds of times.”) Others have had help – from support groups, physicians, therapists, drugs.
But more important than individual efforts to change individual behavior is the positive impact public policy can have on public health. Mandatory immunizations for school, seat-belt laws, laws governing the safety of manufactured automobiles, helmet laws etc., have all had measurable and significant impact on our health. The two most common and important public policy initiatives regarding smoking are taxing tobacco and banning smoking in public places. In the January 27, 2010 JAMA, Mohammed K. Ali and Jeffrey P. Koplan look at “Promoting health through tobacco taxation”.[1] They show that increasing tobacco taxes decreases tobacco use, especially in young people, and thus the morbidity and mortality that comes from tobacco.
The beneficial effect of smoking bans is so enormous it suprises even tobacco control advocates. “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis”, published by David G. Meyers, John S. Neuberger, and Jianghua He in the Journal of the American College of Cardiology, September 29, 2009,[2] examined 11 studies of smoking bans done in 10 different locations and found that there was a 17% overall reduction in acute myocardial infarction (AMI = heart attack) when these bans were implemented, and that the risk incrementally decreased 26% for each year that the ban was in place. In Helena, MT a smoking ban instituted in June 2002 and resulted in a 40% decrease in AMI by the time the ban was suspended by a court order in December. After the ban was lifted, the AMI rate returned to baseline within 6 months. The impact on AMI is in addition to any effect on other diseases, such as cancers, which were not examined in this study (and would take many more years to have an effect). While much of this improvement in the public’s health comes from reducing the impact from second hand smoke on non-smokers, such bans also unquestionably encourage smokers, especially younger ones, to stop smoking. This is particularly true when quitting is something that the smoker had wanted and planned to do, with the smoking ban or increase in the tobacco tax acting as the “final straw”.
Ronald Bayer and Matthew Kelly, in the New England Journal of Medicine January 28, 2010 discuss “Tobacco control and free speech”[3] and look at how the courts are likely to decide on cases brought to them on tobacco control. While not, so far, opposing tobacco bans, the American Civil Liberties Union is supporting objections to limits on tobacco advertising on the basis of their restriction of free speech: “Burt Neuborne of the New York Civil Liberties Union told Congress that the proposed bans represented ‘a vote of no confidence in the capacity of ordinary Americans to judge for themselves how to react to tobacco advertising”. Bayer and Kelly cite the Posadas decision, written by former Chief Justice Rehnquist in 1986, that limited the advertising for a casino. The quote his opinion “It would surely…be a strange constitutional doctrine which would concede to the legislature the authority to totally ban a product or activity [such as gambling] but deny to the legislature the authority to forbid the stimulation of demand for the product or activity [advertising]”. I would argue that it is unreasonable to suggest that we can outlaw products (such as heroin, marijuana) or activities (gambling) but not restrict others (e.g., smoking in public places) and thus most often bans have been supported.
However, the Supreme Court is moving away from the Posadas position, Bayer and Kelly tell us, in the 2001 case of Lorillard Tobacco Company v. Reilly, and given the 2010 Citizens United decision in which the Court has made the bizarre declaration that corporations have First Amendment rights to give money directly to political candidates, it is far from certain that they would support tobacco bans, taxes, or restrictions on advertising in the future. Clearly, these justices who have previously styled themselves as “strict constructionists” looking at original intent”, have clearly demonstrated that they have no such belief, radically making new law and reading their own beliefs into the Constitution. But what is certain is that all these restrictions, without directly forbidding any adult from smoking, have a dramatic positive impact on the public’s health.
Another article in the New England Journal of Medcine, published on-line January 20, 2010, by Kristen Bibbins-Domingo, et. al., looks at the “Projected effect of dietary salt reductions on future cardiovascular disease”, and notes that reducing dietary salt by 3g per day (or about 1/3) would reduce the annual number of deaths from all causes by 44,000 to 92,000, and new cases of coronary heart disease by 60,000 to 120,000, stroke by 32,000 to 66,000 and AMI by 54,000 to 99,000. This is important, because in recent years the emphasis on salt reduction as a method of treating hypertension (high blood pressure), one of the big vehicles for these bad outcomes, has diminished with the marketing of large numbers of anti-hypertensive drugs. We, as physicians and the public, need reminders of the dramatic efficacy of this sort of dietary change.
The article does not address how that reduction might be accomplished; clearly, as with smoking, the effect could occur if people as individuals just reduce their salt intake. But the probability of this happening is again low. Programs such as labeling the salt/sodium content on foods in both grocery stores and restaurants, especially “fast-food” restaurants, have been implemented in a number of cities. Further regulation, actually requiring lowering of the amount of salt in these foods, would have an even greater impact. Unlike smoking bans, which have a great part of their effect through elimination of exposure of non-smokers to secondhand smoke, the benefit of salt restriction is mostly to the individual consumer. However, this does not mean that societal impetus for this change is not a critical part of changing people’s behavior. Indeed, as noted by Mark Doescher, Director of the Rural Health Research Center and the Center for Health Workforce Studies at the University of Washington in his comments on the important new textbook Community Based Health Interventions [4], “…environmental factors, such as safe streets, healthy food choices, and smoke-free establishments govern individual behavior.”
Experts in occupational safety have long recognized that changing individual behavior is the least effective way of increasing safety. If we want to prevent people from slipping on a factory floor and going through a plate glass window, the first choice is architectural (don’t put a plate glass window next to a shop floor where substances may be spilled that people can slip on). The second choice is engineering, or retrofitting (put a steel mesh over the window). The least effective choice is changing human behavior (telling people to be careful!). The dramatic reduction in deaths from car accidents over the last 30 years has had virtually nothing to do with people driving more safely, and everything to do with car manufacture (engines that collapse down instead of into your lap, air bags, etc., all of which were resisted by the automobile industry) and safer road construction. With regard to the health of the public, the same rules apply. Tobacco bans, tobacco taxes, and efforts to reduce salt intake by honest labeling are much more likely to have a salubrious impact than efforts to get people to change their behavior individual by individual. We need to encourage the latter, but because Doescher is correct, we must also implement the policy changes. We must no longer allow the economic benefit to special interests to continue to endanger the public’s health.
[1] Ali MK, Koplan JP, “Promoting health through tobacco taxation”, JAMA 27Jan10;303(4)357-8.
[2] Meyers DG, Neuberger JS, He J, “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis”, J Amer Coll Card 29Sep09;54(14):1249-55.
[3] Bayer R, Kelly M, “Tobacco control and free speech”, NEJM 28Jan10; 262(4):281-3.
[4] Guttmacher S, Kelly PJ, Ruiz-Janecko Y, eds., Community-based health interventions, Jossey-Bass, San Francisco, 2010.
Monday, February 1, 2010
Haiti and Health Reform: We need real leadership
.
There is a lot bad in the world, and compared to people in many places, people in the US are doing OK. The most obvious and well-covered venue of desperation is Haiti, where the earthquake smashed a country that had been set up for failure, figuratively raped and pillaged by wealthy nations, including the United State, for two centuries. Less publicized is the horrific situation in the Congo, characterized by literal rape and pillage as painfully described by Nicholas Kristof in his New York Times Op-Ed January 31, 2010, “Orphaned, Raped and Ignored”. I won’t repeat the details – it is a must-read – but he leads with “Sometimes I wish eastern Congo could suffer an earthquake or a tsunami, so that it might finally get the attention it needs. The barbaric civil war being waged here is the most lethal conflict since World War II and has claimed at least 30 times as many lives as the Haiti earthquake.” And, worse, provides details that almost make one hope that with him.
The American people have responded in a truly humanitarian way to the crisis in Haiti, and it gives me new faith in the American people, if not their leaders. Many of us who have money have written checks and made pledges, but so have those without. People on fixed incomes have sent their last $5 or $10. Writing about her volunteer work with Heart to Heart in the Kansas City suburbs a week or so ago, my friend Pat Kelly writes:
“The number and type of people donating goods to the Heart to Heart trailer this afternoon was moving in itself. The live broadcaster from 1540 AM, a local Hispanic radio station wound up hauling boxes with two members of his family who decided to stay and help. Hispanic families, clearly not wealthy, driving very minimal cars, opened their trunks which were full of bottled water, canned goods, toilet paper. Cars with three infant seats in the back seat pulled out bags and bags just purchased from Target and Walmart with soaps, alcohol, hygienic products. Three different guys in lawn service pick-up trucks stopped by with checks or cash. African-American couples, mostly older, had full back seats of donations. There were at least three times as many Blacks and Hispanic donating as Whites--and this was on Shawnee Mission Parkway at Roe, not in the urban core.”
Yes. These people understand what hard times are. Understand how important it is to share and to help and to give. It is a wonderful response, the only comprehensibly human response, people giving all that they have to give. It is also something the bankers, and too many of the privileged in our national leadership either do not understand or reject. In their selfish cruelty they may disparage such giving as weakness, but of course they are wrong; generosity and caring and social consciousness are strength.
And so what will this mean for health care reform bill, I have no idea. Despite being made fun of by everyone from Barack Obama to Jon Stewart, the Republicans are going to continue to revel in being the “party of no”, of sitting on their hands and glowering at the State of the Union, of being completely uncivil when the President walks into their den, and hoping (no, believing) that acting in this way is going to get them “street cred” with the American people. They are, as identified by Frank Rich (“The State of the Union Is Comatose”, NY Times January 31, 2010), the “unpatriotic opposition”.
May it will; maybe the majority of the American people are attracted to mean looking white guys with their arms folded, responding to controversy in a manner that suggests they haven’t had a thought in a long time, but I don’t think so. Because so many of us are, as our response to the crisis in Haiti demonstrates, a caring people. On the other hand, it could be their only available strategy, since every time they trot out “facts” they are completely wrong, and a lot of folks seem to have the bad taste to want to point this out. So, at this point, I will wait and see what happens. There is a better solution – Medicare for all, pass it, let it happen, let the Republicans and insurance companies choke on their bile, and let us move forward. Obama gave a good speech; it is time for him to follow it up.
Health care is only the start. Dealing with the financial industry, in a firm and decisive manner, is also on the agenda. There have been many references to the administration of Franklin Roosevelt, and in particular the aggressive investigations led by Ferdinand Pecora. Citing the actions of a more recent president, Frank Rich’s January 24, 2010 column “After the Massachusetts Massacre”, describes John Kennedy’s dressing down of Richard Reeves, the president of US Steel, in 1962. I look, however, to an even earlier president, Theodore Roosevelt, who broke up the Standard Oil monopoly. If we have banks that are “too big to fail”, the obvious solution is: let’s not have them; break them up. I think that the fact that the one thing that everyone from every sector can agree on is that the banks and financial sector is comprised of heartless, evil people whose greed plunged our nation and world into the worst financial crisis since 1929, it is time to take strong action. Who will oppose it save the Geithners and Summers’? Here is another opportunity for the Republicans, who have been playing populist like they were George W. Bush paintball warriors; they can rush to the defense of Goldman Sachs and Citigroup and see if the American people support them. I don’t think so.
President Obama said many good things in his State of the Union speech (and some not so good ones), but he needs to follow these statements up. Rich (Jan 31) suggests “Obama should turn up the heat on both the G.O.P’s record of fiscal recklessness and its mad-dog obstructionism. He should stop paying lip service to the fantasy that his Congressional opposition has serious ideas to contribute to the cleanup. Better still, he should publicize exactly what those ‘ideas’ are.” His budget proposal is not encouraging, emphasizing increases in defense spending and decreases in domestic services.
There is a lot to do, and there are leaders who get it. As an underlying assumption, I believe that the best statement was: “In these difficult times, the government believes it is important to continue working toward a society in which people feel a sense of togetherness, respect one another and share responsibility.” Absolutely.
Of course, that was not President Obama, but Queen Beatrix of the Netherlands in her Speech from the Throne (NY Times, January 27, 2010). But I keep hoping that the US can also have leaders who can get it, and can act on it. What would be really wonderful is if they could act as nobly as the plain folks in Kansas City.
.
There is a lot bad in the world, and compared to people in many places, people in the US are doing OK. The most obvious and well-covered venue of desperation is Haiti, where the earthquake smashed a country that had been set up for failure, figuratively raped and pillaged by wealthy nations, including the United State, for two centuries. Less publicized is the horrific situation in the Congo, characterized by literal rape and pillage as painfully described by Nicholas Kristof in his New York Times Op-Ed January 31, 2010, “Orphaned, Raped and Ignored”. I won’t repeat the details – it is a must-read – but he leads with “Sometimes I wish eastern Congo could suffer an earthquake or a tsunami, so that it might finally get the attention it needs. The barbaric civil war being waged here is the most lethal conflict since World War II and has claimed at least 30 times as many lives as the Haiti earthquake.” And, worse, provides details that almost make one hope that with him.
The American people have responded in a truly humanitarian way to the crisis in Haiti, and it gives me new faith in the American people, if not their leaders. Many of us who have money have written checks and made pledges, but so have those without. People on fixed incomes have sent their last $5 or $10. Writing about her volunteer work with Heart to Heart in the Kansas City suburbs a week or so ago, my friend Pat Kelly writes:
“The number and type of people donating goods to the Heart to Heart trailer this afternoon was moving in itself. The live broadcaster from 1540 AM, a local Hispanic radio station wound up hauling boxes with two members of his family who decided to stay and help. Hispanic families, clearly not wealthy, driving very minimal cars, opened their trunks which were full of bottled water, canned goods, toilet paper. Cars with three infant seats in the back seat pulled out bags and bags just purchased from Target and Walmart with soaps, alcohol, hygienic products. Three different guys in lawn service pick-up trucks stopped by with checks or cash. African-American couples, mostly older, had full back seats of donations. There were at least three times as many Blacks and Hispanic donating as Whites--and this was on Shawnee Mission Parkway at Roe, not in the urban core.”
Yes. These people understand what hard times are. Understand how important it is to share and to help and to give. It is a wonderful response, the only comprehensibly human response, people giving all that they have to give. It is also something the bankers, and too many of the privileged in our national leadership either do not understand or reject. In their selfish cruelty they may disparage such giving as weakness, but of course they are wrong; generosity and caring and social consciousness are strength.
And so what will this mean for health care reform bill, I have no idea. Despite being made fun of by everyone from Barack Obama to Jon Stewart, the Republicans are going to continue to revel in being the “party of no”, of sitting on their hands and glowering at the State of the Union, of being completely uncivil when the President walks into their den, and hoping (no, believing) that acting in this way is going to get them “street cred” with the American people. They are, as identified by Frank Rich (“The State of the Union Is Comatose”, NY Times January 31, 2010), the “unpatriotic opposition”.
May it will; maybe the majority of the American people are attracted to mean looking white guys with their arms folded, responding to controversy in a manner that suggests they haven’t had a thought in a long time, but I don’t think so. Because so many of us are, as our response to the crisis in Haiti demonstrates, a caring people. On the other hand, it could be their only available strategy, since every time they trot out “facts” they are completely wrong, and a lot of folks seem to have the bad taste to want to point this out. So, at this point, I will wait and see what happens. There is a better solution – Medicare for all, pass it, let it happen, let the Republicans and insurance companies choke on their bile, and let us move forward. Obama gave a good speech; it is time for him to follow it up.
Health care is only the start. Dealing with the financial industry, in a firm and decisive manner, is also on the agenda. There have been many references to the administration of Franklin Roosevelt, and in particular the aggressive investigations led by Ferdinand Pecora. Citing the actions of a more recent president, Frank Rich’s January 24, 2010 column “After the Massachusetts Massacre”, describes John Kennedy’s dressing down of Richard Reeves, the president of US Steel, in 1962. I look, however, to an even earlier president, Theodore Roosevelt, who broke up the Standard Oil monopoly. If we have banks that are “too big to fail”, the obvious solution is: let’s not have them; break them up. I think that the fact that the one thing that everyone from every sector can agree on is that the banks and financial sector is comprised of heartless, evil people whose greed plunged our nation and world into the worst financial crisis since 1929, it is time to take strong action. Who will oppose it save the Geithners and Summers’? Here is another opportunity for the Republicans, who have been playing populist like they were George W. Bush paintball warriors; they can rush to the defense of Goldman Sachs and Citigroup and see if the American people support them. I don’t think so.
President Obama said many good things in his State of the Union speech (and some not so good ones), but he needs to follow these statements up. Rich (Jan 31) suggests “Obama should turn up the heat on both the G.O.P’s record of fiscal recklessness and its mad-dog obstructionism. He should stop paying lip service to the fantasy that his Congressional opposition has serious ideas to contribute to the cleanup. Better still, he should publicize exactly what those ‘ideas’ are.” His budget proposal is not encouraging, emphasizing increases in defense spending and decreases in domestic services.
There is a lot to do, and there are leaders who get it. As an underlying assumption, I believe that the best statement was: “In these difficult times, the government believes it is important to continue working toward a society in which people feel a sense of togetherness, respect one another and share responsibility.” Absolutely.
Of course, that was not President Obama, but Queen Beatrix of the Netherlands in her Speech from the Throne (NY Times, January 27, 2010). But I keep hoping that the US can also have leaders who can get it, and can act on it. What would be really wonderful is if they could act as nobly as the plain folks in Kansas City.
.
Wednesday, January 27, 2010
Health is more than Medical Care
.
Bob Herbert’s column in the New York Times, January 23, 2010, “They still don’t get it”, is one of many recent pieces that articulately criticize the administration for pursuing policies that benefit the wealthy and the elite, and ignore the absolutely justifiable anger of the majority of American people. That anger is being stoked and ridden by the Republicans, as it was by Obama in 2008, because they are out of power. There is no question that, if the Repubs were in power, they would be even worse, and cater even more to that elite (ref: see administration of GW Bush, 2001-09.) One of the issues that Herbert takes on is health reform: “While the nation was suffering through the worst economy since the Depression, the Democrats wasted a year squabbling like unruly toddlers over health insurance legislation.” Herbert is not opposed to health reform, but rather the outrageous way that this sausage has been made: “No one in his or her right mind could have believed that a workable, efficient, cost-effective system could come out of the monstrously ugly plan that finally emerged from the Senate after long months of shady alliances, disgraceful back-room deals, outlandish payoffs and abject capitulation to the insurance companies and giant pharmaceutical outfits. The public interest? Forget about it.”
With the election of the 41st Republican senator – under Senate rules, 41 votes constitutes a majority in terms of blocking legislation – we have heard many opinions on what should happen with health reform. The Republicans and the right-wing, who, despite their opportunist populism stand firmly in the grasp of “insurance companies and giant pharmaceutical outfits” are predictably calling health reform “dead” and reveling in the possibility that the system won’t change at all. This, of course, is a disaster; the folks who voted for Scott Brown in Massachusetts because they were convinced by demagogues that they would lose their current health benefits will continue to lose them anyway, not because of health reform legislation but because that’s where it was headed – higher cost, lower benefits. Some progressives, including Paul Krugman (“Do the right thing”, January 22, 2010), and physician-writer Atul Gawande (in his Democracy Now! Interview with Amy Goodman on January 5, 2010), call for passage of the current plan because it will, in fact, benefit a lot of people. Krugman says the House should just pass Senate bill to avoid any further votes in the Senate, which might lose. There is a lot to be said for this position. Others, including those I respect most from Physicians for a National Health Program, call for scrapping this whole bill and passing a single-payer Medicare for All program, which is absolutely the right answer, but not going to happen. (Nonetheless, I will, and I urge everyone, to write their representatives every day demanding it!)
While I support single-payer health insurance as the necessary pre-condition for improving health care for the American people, it is also clear that the process of self-interest politics in the formation of the Senate and House bills (in which the self-interest of the most wealthy and powerful is the biggest influence) has moved the discussion so much to medical care insurance coverage and access that we lose sight of the ultimate goal, greater health. In an excellent “Perspective” in the New England Journal of Medicine, January 14, 2010, “Ranking 37th – measuring the performance of the US health care system”, Chistopher J.L. Murray and Julio Frenk review the 2000 World Health Organization rankings of health status in different countries in the world. They remind us that “It is hard to ignore that in 2006, the United States was number 1 in terms of health care spending per capita but ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy,” and that the probability of death for men 15-60 has dropped dramatically more slowly since 1974 in the US than in many other countries.
Murray and Frenk also remind us of “the vast number of preventable deaths associated with smoking (465,000 per year), hypertension (395,000), obesity (216,000), physical inactivity (191,000), high blood glucose levels (190,000), high levels of low-density lipoprotein cholesterol (113,000), and other dietary risk factors”. We may not see these numbers every day, but health professionals and policy people know (or should know) them. We have certainly seen calls from many sectors, from this blog to the President, for a realignment of funding priorities from expensive procedures to prevention, from high-tech subspecialty care to primary care, from huge expenses at the end of life to strategies that will extend healthy life, and these numbers emphasize how important those changes are.
But those changes only address health care, and more usually medical care. This can be a diversion, from other, maybe more important, policies that truly will promote health. Even if we can produce more primary care physicians (and other providers), even if we offer “pay-for-performance” type incentives for physicians to do “quality care”, even if we actually pay as much for spending an hour counseling and working with a person to stop smoking, change their diet, and exercise, as we do for a cardiac catheterization or colonoscopy, the problems listed by Murray and Frenk require behavioral change on the part of people. Doctors can help, by counseling, by prescribing drugs for the conditions (e.g., hypertension, diabetes) that may be drug-susceptible, but people themselves are going to have to be the ones who change their diets, exercise more, stop smoking, take those medications.
Please note that I am not one of those who wants to place the blame on individuals, and excuse physicians and other health professionals from their own responsibilities (“I told them to lose weight, to stop smoking, to exercise! They didn’t do it! They are not compliant!”). It is important, however, to look at these problems from a larger social perspective. In the paragraph above I purposely used the word “people”, not, as is popular, “individuals”. Because while individuals, if they are highly motivated enough (and this is helped by having higher income and education and social class) can change these behaviors -- and have, in many cases, such as the dramatic reduction in the prevalence of smoking, these are really societal issues. This sort of behavioral change is hard to do – stopping an addiction like nicotine is harder than heroin, but is nothing compared to changing your diet from foods that taste good (and yes, while to some degree poor food choices come from habit and culture, the fact is that sugar and fat taste good!) to those that are more healthful, to limiting intake of excess calories. And exercise is hard, not only when you are already fat, out of shape and a smoker, but when you are working 2 or 3 jobs, live in a neighborhood that is unsafe, and have to try to fit in taking care of your children.
Changing these health parameters is not going to happen solely from everyone having health insurance and access to medical care, paying physicians for “quality”, or increasing the number of primary care providers, or completely changing the premises of medical care reimbursement. It is going to require major societal change. Some has begun to happen – public smoking bans in many cities and states, calorie labels on fast foods in some cities, removal of high calorie snack and drink machines from some schools. But what it needs is not only for these actions to be universal, it will require much more. Stricter regulation of advertising of junk food to children, higher taxes on it, and less availability. The messages for eating healthful food need to be louder and more frequent than the messages to do the opposite. We have to ban insidious campaigns like “drink wisely” (i.e., "do drink"). And have strict limits on access to firearms. And we have to rebuild our communities to encourage not only purposeful exercise (“going to the gym”) but activity as a part of daily life: walking instead of driving to school, shopping, work.
Of course, for all of these changes, there will be powerful lobbies against it –even the easy ones (smoking bans, labeling) not to mention the generations it will take to significantly modify our built environment. And if you thought that the opposition to meaningful health care insurance reform was powerful, you ain’t seen nothing yet!
.
Bob Herbert’s column in the New York Times, January 23, 2010, “They still don’t get it”, is one of many recent pieces that articulately criticize the administration for pursuing policies that benefit the wealthy and the elite, and ignore the absolutely justifiable anger of the majority of American people. That anger is being stoked and ridden by the Republicans, as it was by Obama in 2008, because they are out of power. There is no question that, if the Repubs were in power, they would be even worse, and cater even more to that elite (ref: see administration of GW Bush, 2001-09.) One of the issues that Herbert takes on is health reform: “While the nation was suffering through the worst economy since the Depression, the Democrats wasted a year squabbling like unruly toddlers over health insurance legislation.” Herbert is not opposed to health reform, but rather the outrageous way that this sausage has been made: “No one in his or her right mind could have believed that a workable, efficient, cost-effective system could come out of the monstrously ugly plan that finally emerged from the Senate after long months of shady alliances, disgraceful back-room deals, outlandish payoffs and abject capitulation to the insurance companies and giant pharmaceutical outfits. The public interest? Forget about it.”
With the election of the 41st Republican senator – under Senate rules, 41 votes constitutes a majority in terms of blocking legislation – we have heard many opinions on what should happen with health reform. The Republicans and the right-wing, who, despite their opportunist populism stand firmly in the grasp of “insurance companies and giant pharmaceutical outfits” are predictably calling health reform “dead” and reveling in the possibility that the system won’t change at all. This, of course, is a disaster; the folks who voted for Scott Brown in Massachusetts because they were convinced by demagogues that they would lose their current health benefits will continue to lose them anyway, not because of health reform legislation but because that’s where it was headed – higher cost, lower benefits. Some progressives, including Paul Krugman (“Do the right thing”, January 22, 2010), and physician-writer Atul Gawande (in his Democracy Now! Interview with Amy Goodman on January 5, 2010), call for passage of the current plan because it will, in fact, benefit a lot of people. Krugman says the House should just pass Senate bill to avoid any further votes in the Senate, which might lose. There is a lot to be said for this position. Others, including those I respect most from Physicians for a National Health Program, call for scrapping this whole bill and passing a single-payer Medicare for All program, which is absolutely the right answer, but not going to happen. (Nonetheless, I will, and I urge everyone, to write their representatives every day demanding it!)
While I support single-payer health insurance as the necessary pre-condition for improving health care for the American people, it is also clear that the process of self-interest politics in the formation of the Senate and House bills (in which the self-interest of the most wealthy and powerful is the biggest influence) has moved the discussion so much to medical care insurance coverage and access that we lose sight of the ultimate goal, greater health. In an excellent “Perspective” in the New England Journal of Medicine, January 14, 2010, “Ranking 37th – measuring the performance of the US health care system”, Chistopher J.L. Murray and Julio Frenk review the 2000 World Health Organization rankings of health status in different countries in the world. They remind us that “It is hard to ignore that in 2006, the United States was number 1 in terms of health care spending per capita but ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy,” and that the probability of death for men 15-60 has dropped dramatically more slowly since 1974 in the US than in many other countries.
Murray and Frenk also remind us of “the vast number of preventable deaths associated with smoking (465,000 per year), hypertension (395,000), obesity (216,000), physical inactivity (191,000), high blood glucose levels (190,000), high levels of low-density lipoprotein cholesterol (113,000), and other dietary risk factors”. We may not see these numbers every day, but health professionals and policy people know (or should know) them. We have certainly seen calls from many sectors, from this blog to the President, for a realignment of funding priorities from expensive procedures to prevention, from high-tech subspecialty care to primary care, from huge expenses at the end of life to strategies that will extend healthy life, and these numbers emphasize how important those changes are.
But those changes only address health care, and more usually medical care. This can be a diversion, from other, maybe more important, policies that truly will promote health. Even if we can produce more primary care physicians (and other providers), even if we offer “pay-for-performance” type incentives for physicians to do “quality care”, even if we actually pay as much for spending an hour counseling and working with a person to stop smoking, change their diet, and exercise, as we do for a cardiac catheterization or colonoscopy, the problems listed by Murray and Frenk require behavioral change on the part of people. Doctors can help, by counseling, by prescribing drugs for the conditions (e.g., hypertension, diabetes) that may be drug-susceptible, but people themselves are going to have to be the ones who change their diets, exercise more, stop smoking, take those medications.
Please note that I am not one of those who wants to place the blame on individuals, and excuse physicians and other health professionals from their own responsibilities (“I told them to lose weight, to stop smoking, to exercise! They didn’t do it! They are not compliant!”). It is important, however, to look at these problems from a larger social perspective. In the paragraph above I purposely used the word “people”, not, as is popular, “individuals”. Because while individuals, if they are highly motivated enough (and this is helped by having higher income and education and social class) can change these behaviors -- and have, in many cases, such as the dramatic reduction in the prevalence of smoking, these are really societal issues. This sort of behavioral change is hard to do – stopping an addiction like nicotine is harder than heroin, but is nothing compared to changing your diet from foods that taste good (and yes, while to some degree poor food choices come from habit and culture, the fact is that sugar and fat taste good!) to those that are more healthful, to limiting intake of excess calories. And exercise is hard, not only when you are already fat, out of shape and a smoker, but when you are working 2 or 3 jobs, live in a neighborhood that is unsafe, and have to try to fit in taking care of your children.
Changing these health parameters is not going to happen solely from everyone having health insurance and access to medical care, paying physicians for “quality”, or increasing the number of primary care providers, or completely changing the premises of medical care reimbursement. It is going to require major societal change. Some has begun to happen – public smoking bans in many cities and states, calorie labels on fast foods in some cities, removal of high calorie snack and drink machines from some schools. But what it needs is not only for these actions to be universal, it will require much more. Stricter regulation of advertising of junk food to children, higher taxes on it, and less availability. The messages for eating healthful food need to be louder and more frequent than the messages to do the opposite. We have to ban insidious campaigns like “drink wisely” (i.e., "do drink"). And have strict limits on access to firearms. And we have to rebuild our communities to encourage not only purposeful exercise (“going to the gym”) but activity as a part of daily life: walking instead of driving to school, shopping, work.
Of course, for all of these changes, there will be powerful lobbies against it –even the easy ones (smoking bans, labeling) not to mention the generations it will take to significantly modify our built environment. And if you thought that the opposition to meaningful health care insurance reform was powerful, you ain’t seen nothing yet!
.
Thursday, January 21, 2010
Harvard Medical School limits outside income: a good start
.
Partners Health Care, the physicians group comprising the clinical faculty of the Harvard Medical School at Massachusetts General Hospital and Brigham and Women’s Hospital, has recently set “strict” limits on the compensation that about “two dozen senior officials” (including department chairs, vice presidents and others) can receive from serving on the corporate boards of biotechnology and pharmaceutical companies, according to Duff Wilson in the New York Times, January 3, 2010 , Harvard Teaching Hospitals Cap Outside Pay. These physicians will also be prohibited from receiving any speaking fees from drug companies. The article indicates that many medical schools have put limits on such outside income, but that Harvard’s are the strictest yet. And consequential, because Harvard has so many leaders who sit on such boards. Apparently, the ban on speaking fees was decided first by the policy committee, and then the board income was limited so as not to limit outside income for junior faculty (who may speak for drug companies) but not senior leaders (who are more likely to be on the boards). There is no indication of limits on the participation of anyone on boards of other types of corporations, although biotechnology and pharmaceutical, along with medical device companies, are the most likely to create a conflict of interest.
Many do not see these restrictions as enough. The chair of the Partners’ policy committee, that wrote the rules, distinguished cardiologist Eugene Braunwald, is quoted as saying “We’re the first to go in this deep, and we’re still into it only up to our knees.” Former New England Journal of Medicine editor and Harvard professor emeritus Arnold Relman definitely thinks that they are too weak: “I think that’s a gross conflict for an official of an academic medical center to be on the board of a pharmaceutical company...It’s happening more and more around the country…If it isn’t stopped, I think the academic institutions are going to lose the confidence of the country and the government and they will no longer deserve the tax exemption or anything else. They will be part of industry itself.” Regular people may not see the restrictions, to $5,000 a day (based on $500 an hour for a 10-hour day of actual work on the board) as too severe, but they are not moving in the world of corporate boards. Dennis Ausiello MD, chair of medicine at Mass General, has received over $200,000 since 2006 from sitting on the board of the pharmaceutical giant Pfizer. “I certainly think I should be compensated fairly and symmetrically with my fellow board members,” he says. However, he will abide by the rules. “I’m not there to make money… if my institutions rule otherwise [i.e., against being compensated as are his fellow board members], as they have, I will continue to serve on the board.”
Clearly, Ausiello has a different perspective than Relman, because he believes that he makes a positive contribution being on the board: “I’m very proud of my board work,” while Relman thinks the very presence of medical school faculty on boards is corrupting its mission. Interestingly, both the committees seeking to restrict the participation and corporate pay experts agree that paying board members based on corporate performance and profit ties them to the profitability of the corporation. The Times notes that “Thomas Donaldson, a professor of business ethics at the Wharton School of the University of Pennsylvania…who advises large companies on corporate governance, said dual roles in a hospital and at a drug maker were ‘dicey at best’ because a director’s duty is to look out for the corporation’s financial interests.” He said: “It strikes me as a breath of fresh air in a room that’s getting progressively more stale. I hope this will set a standard for others — hospitals, medical schools.” The Harvard rules specifically prohibit this, believing that pay for work (@ $500/hr) at least has the chance of allowing its faculty to maintain some scientific integrity.
The issue can be complicated for insiders. Deborah Powell MD, former dean of the medical school at the University of Minnesota and an advocate for policies that encourage restraint, herself accepted a paid position on the board of Pepsico. Many believe that her subsequent firing was due, in part, to negative publicity from this action. (U of M medical school reorganizes; dean out by summer, Tim Post, Minnesota Public Radio, January 29, 2009). The American Academy of Family Physicians (AAFP) has recently developed a “corporate partnership” with Coca-Cola that has received a great deal of criticism both within and outside the family medicine community – criticism that has not resulted in the AAFP ending the relationship. Which is a greater conflict of interest for physicians and medical school faculty members – alliances with companies, such as Coke and Pepsi, whose products are clearly detrimental to health, or sitting on the boards of corporations that make medical and pharmaceutical products? I leave the call to you; to me they are both rotten. Corporations want them to get the imprimatur of science and health that these relationships provide. Organizations like AAFP want them for the money. Presumably the individuals on the faculty of Harvard and other medical schools also like the money, but also may, like Drs. Ausiello and Powell, think that they can make significant positive contributions to health through their roles on the boards. And, if these people are full-time employees at their main job, who should get the money that it engenders? Harvard is, as noted, limiting the income, but is allowing corporations to use the rest of the money that the board member would have gotten paid as a charitable donation to any charity not linked to Harvard, Partners, or the hospitals. That deals with the money issue, but still leaves the questions about the ethics of participation, even for free, that are raised by Dr. Relman and others.
Interestingly, the Times article cites the Partners’ decision as, in part, due to the fact that “Harvard, in particular, has come under scrutiny from Senator Charles E. Grassley of Iowa, a leader of Congressional inquiries into the influence of money in medicine.” I say “interestingly” because Grassley, the Finance Committee's ranking Republican, received more than $2 million from the health and insurance sectors since 2003 (Industry Cash Flowed To Drafters of Reform, Washington Post, July 21, 2009). Of course, like the medical school faculty who believe that they are doing important work and are not influenced by the pay (which Sen. Grassley doubts), Grassley himself says the campaign contributions have no effect on his positions (Grassley: Campaign Contributions Hold No Sway, Press Center from the Des Moines Register, August 31, 2009). Double standard? Of course. Ironically, Grassley uses his investigations into the policies of places like Harvard as evidence that he is not “bought” by those interests!
Harvard is taking the right first steps and those principles should guide other medical schools in the future to take even stronger action. And the same should be done for contributions to members of Congress.
.
Partners Health Care, the physicians group comprising the clinical faculty of the Harvard Medical School at Massachusetts General Hospital and Brigham and Women’s Hospital, has recently set “strict” limits on the compensation that about “two dozen senior officials” (including department chairs, vice presidents and others) can receive from serving on the corporate boards of biotechnology and pharmaceutical companies, according to Duff Wilson in the New York Times, January 3, 2010 , Harvard Teaching Hospitals Cap Outside Pay. These physicians will also be prohibited from receiving any speaking fees from drug companies. The article indicates that many medical schools have put limits on such outside income, but that Harvard’s are the strictest yet. And consequential, because Harvard has so many leaders who sit on such boards. Apparently, the ban on speaking fees was decided first by the policy committee, and then the board income was limited so as not to limit outside income for junior faculty (who may speak for drug companies) but not senior leaders (who are more likely to be on the boards). There is no indication of limits on the participation of anyone on boards of other types of corporations, although biotechnology and pharmaceutical, along with medical device companies, are the most likely to create a conflict of interest.
Many do not see these restrictions as enough. The chair of the Partners’ policy committee, that wrote the rules, distinguished cardiologist Eugene Braunwald, is quoted as saying “We’re the first to go in this deep, and we’re still into it only up to our knees.” Former New England Journal of Medicine editor and Harvard professor emeritus Arnold Relman definitely thinks that they are too weak: “I think that’s a gross conflict for an official of an academic medical center to be on the board of a pharmaceutical company...It’s happening more and more around the country…If it isn’t stopped, I think the academic institutions are going to lose the confidence of the country and the government and they will no longer deserve the tax exemption or anything else. They will be part of industry itself.” Regular people may not see the restrictions, to $5,000 a day (based on $500 an hour for a 10-hour day of actual work on the board) as too severe, but they are not moving in the world of corporate boards. Dennis Ausiello MD, chair of medicine at Mass General, has received over $200,000 since 2006 from sitting on the board of the pharmaceutical giant Pfizer. “I certainly think I should be compensated fairly and symmetrically with my fellow board members,” he says. However, he will abide by the rules. “I’m not there to make money… if my institutions rule otherwise [i.e., against being compensated as are his fellow board members], as they have, I will continue to serve on the board.”
Clearly, Ausiello has a different perspective than Relman, because he believes that he makes a positive contribution being on the board: “I’m very proud of my board work,” while Relman thinks the very presence of medical school faculty on boards is corrupting its mission. Interestingly, both the committees seeking to restrict the participation and corporate pay experts agree that paying board members based on corporate performance and profit ties them to the profitability of the corporation. The Times notes that “Thomas Donaldson, a professor of business ethics at the Wharton School of the University of Pennsylvania…who advises large companies on corporate governance, said dual roles in a hospital and at a drug maker were ‘dicey at best’ because a director’s duty is to look out for the corporation’s financial interests.” He said: “It strikes me as a breath of fresh air in a room that’s getting progressively more stale. I hope this will set a standard for others — hospitals, medical schools.” The Harvard rules specifically prohibit this, believing that pay for work (@ $500/hr) at least has the chance of allowing its faculty to maintain some scientific integrity.
The issue can be complicated for insiders. Deborah Powell MD, former dean of the medical school at the University of Minnesota and an advocate for policies that encourage restraint, herself accepted a paid position on the board of Pepsico. Many believe that her subsequent firing was due, in part, to negative publicity from this action. (U of M medical school reorganizes; dean out by summer, Tim Post, Minnesota Public Radio, January 29, 2009). The American Academy of Family Physicians (AAFP) has recently developed a “corporate partnership” with Coca-Cola that has received a great deal of criticism both within and outside the family medicine community – criticism that has not resulted in the AAFP ending the relationship. Which is a greater conflict of interest for physicians and medical school faculty members – alliances with companies, such as Coke and Pepsi, whose products are clearly detrimental to health, or sitting on the boards of corporations that make medical and pharmaceutical products? I leave the call to you; to me they are both rotten. Corporations want them to get the imprimatur of science and health that these relationships provide. Organizations like AAFP want them for the money. Presumably the individuals on the faculty of Harvard and other medical schools also like the money, but also may, like Drs. Ausiello and Powell, think that they can make significant positive contributions to health through their roles on the boards. And, if these people are full-time employees at their main job, who should get the money that it engenders? Harvard is, as noted, limiting the income, but is allowing corporations to use the rest of the money that the board member would have gotten paid as a charitable donation to any charity not linked to Harvard, Partners, or the hospitals. That deals with the money issue, but still leaves the questions about the ethics of participation, even for free, that are raised by Dr. Relman and others.
Interestingly, the Times article cites the Partners’ decision as, in part, due to the fact that “Harvard, in particular, has come under scrutiny from Senator Charles E. Grassley of Iowa, a leader of Congressional inquiries into the influence of money in medicine.” I say “interestingly” because Grassley, the Finance Committee's ranking Republican, received more than $2 million from the health and insurance sectors since 2003 (Industry Cash Flowed To Drafters of Reform, Washington Post, July 21, 2009). Of course, like the medical school faculty who believe that they are doing important work and are not influenced by the pay (which Sen. Grassley doubts), Grassley himself says the campaign contributions have no effect on his positions (Grassley: Campaign Contributions Hold No Sway, Press Center from the Des Moines Register, August 31, 2009). Double standard? Of course. Ironically, Grassley uses his investigations into the policies of places like Harvard as evidence that he is not “bought” by those interests!
Harvard is taking the right first steps and those principles should guide other medical schools in the future to take even stronger action. And the same should be done for contributions to members of Congress.
.
Saturday, January 16, 2010
Cancer Care and Hospital Advertising
.
The December 19, 2009 issue of the New York Times contains an article entitled Cancer Center Ads Use Emotion More Than Fact. The piece, by Natasha Singer, documents the extensive use of advertising by hospitals to attract cancer patients, and decries the appeal to people’s emotions at a time of great vulnerability, after they have received a cancer diagnosis. These appeals contain testimonials from people who were “cured” or had a good outcome (or at least think, at the time of the testimonials, that they had a good outcome), and imply – sometimes frankly state – that their cancer care is better than their competitors’. Those competitors may be other hospitals in the same metropolitan area, or, in the case of centers that have received special National Cancer Institute (NCI) “cancer center” designation, or in the case of the “top” centers (e.g., MD Anderson in Houston, Dana-Farber in Boston, in New York ) each other.
The issue is that this advertising does not have to be based on fact. This is not to say that the actual people in the testimonials are lying, but that there is no requirement for data on statistical outcomes from these hospitals before they produce their advertising. The individual patient may have had a good outcome, but has no way of knowing if the outcome would have been as good (or better) somewhere else. The article documents assertions of superlatives, such as a doctor having the “highest cure rates” and “lowest risk”, which a reasonable person might infer was based on data comparing that doctor’s, or that hospital’s, results to others. However it turns out that they are based on anecdotes, something that would be completely unacceptable in the reporting of scientific results. One expert noted that “There seems to be a disconnect between the business end of the cancer treatment industrial complex and the physicians on the front lines treating patients,” a dramatic understatement. “This isn’t retail advertising,” said the president of a Manhattan agency that developed ads for Mount Sinai hospital, “This is reputation advertising. There is a very big difference.”
Why hospitals want to advertise their cancer care (or their care for any other profitable “service line” such as, the article notes, cardiovascular disease or cosmetic surgery) is obvious – to make money. Though most of them are “not-for-profit”, all that means is that the “profits” don’t go to shareholders, but they can certainly be used by the hospital for expansion or creations of new and better service lines. And higher salaries and bonuses for executives (and physicians). Does it improve people’s health? Well, to a certain degree competition between hospitals does; like competition in any industry it operates against complacency, against “doing what we’ve always done”, against being satisfied with less than “the best”, because if it is possible to do better, there is the chance that your competitor will do better, and take away your business. It is also reasonable to advertise, so that people know how well you are doing. However, when the advertising is not based on real outcomes data, but purports to be, that is, it indicates – possibly not knowingly untruthfully but without evidence to back it up – that is at best misleading, and possibly unethical.
From a health perspective, a community needs a certain capacity for care of cancer patients – or any patients. That community may be a part of a city, or a city, or a metropolitan area, or in the case of rarer cancers, a region or even the nation. Excess capacity is extremely costly – if hospital A gets most of the cancer “business” in town, so hospital B chooses to invest heavily in building a new cancer-treatment facility (including, by the way, with public funds, since because they are not-for-profit, donations are philanthropy and tax-deductible), we now have excess capacity in the community, and a great deal of extra cost. To the extent that this represents a competition that results in better care, as discussed above, it may be a good thing – but the hospitals should have to document that there is actually better care provided, something almost never done. And, if it is going to spend a lot of money to create excess capacity in the community, the hospital should have to use the traditional method of raising capital and not be able to use tax-deductible contributions for this purpose (but, of course, they do).
There is another problem, which I mentioned briefly above. Hospitals do not heavily (and possibly deceptively) advertise all their services; like other businesses they advertise the profitable services. In general, services (“product lines”) are profitable because the current payment system reimburses for these services far more than the cost of delivering them. Cancer is in this category, because of the enormous markups for providing chemotherapy drugs (this is in addition to the enormous markups charged by the manufacturers). So are cardiovascular procedures, neurosurgical procedures, and of course cosmetic surgery. Hospitals do not heavily advertise the care that they provide (even if it is in fact excellent and better than others’ based on real data) if they don’t make as much, or even lose, money. This includes “regular” medical diseases, as well as very costly special services including much trauma and burn care. Pediatrics is a special case; in general (other than, of course, pediatric cancer care, for the same reasons as adult cancer care, and neonatal intensive care) does not make money, so general hospitals don’t heavily advertise it. “Children’s Hospitals”, however, are often among the greatest recipients of philanthropy in a community, and this is their main source of revenue, so advertising what they do makes sense for them in order to keep their name in front of donors.
We have become used to hearing (including from me) cautions about the greed and influence of the health insurance and the pharmaceutical and device manufacturers on health care, on health legislation and on politicians. These companies are for-profit and interested in their bottom lines, not on the impact that they have on health itself. Much of this is discussed in the New York Times article Health Lobby takes fight to the states on December 29, 2009, but as I have noted, it is the health care industry lobby, not the health lobby. We would have hoped that our communities’ hospitals would see themselves as more interested in our health, but this sort of advertising makes it clear that, non-profit though they may be, they are the health care industry.
Where does this leave us? It leaves us with the need to develop, and publicly report, good measures of outcomes for physicians and hospitals, as called for by many experts, notably Institute for Healthcare Improvement director Don Berwick, MD[1]. Otherwise people will continue to choose hospitals and doctors based on reputation and the quality of their “hotel facilities” rather than on the quality of their care. Pending that, we need to remember to see all health care advertising, including that from doctors and hospitals, as precisely that, advertising, and not confuse those claims with the scientific evidence that we hope will guide our care.
[1] Berwick, D., “Measuring physicians’ quality and performance: adrift on Lake Wobegon”, JAMA Dec9,2009;301:2485-6
.
The December 19, 2009 issue of the New York Times contains an article entitled Cancer Center Ads Use Emotion More Than Fact. The piece, by Natasha Singer, documents the extensive use of advertising by hospitals to attract cancer patients, and decries the appeal to people’s emotions at a time of great vulnerability, after they have received a cancer diagnosis. These appeals contain testimonials from people who were “cured” or had a good outcome (or at least think, at the time of the testimonials, that they had a good outcome), and imply – sometimes frankly state – that their cancer care is better than their competitors’. Those competitors may be other hospitals in the same metropolitan area, or, in the case of centers that have received special National Cancer Institute (NCI) “cancer center” designation, or in the case of the “top” centers (e.g., MD Anderson in Houston, Dana-Farber in Boston, in New York ) each other.
The issue is that this advertising does not have to be based on fact. This is not to say that the actual people in the testimonials are lying, but that there is no requirement for data on statistical outcomes from these hospitals before they produce their advertising. The individual patient may have had a good outcome, but has no way of knowing if the outcome would have been as good (or better) somewhere else. The article documents assertions of superlatives, such as a doctor having the “highest cure rates” and “lowest risk”, which a reasonable person might infer was based on data comparing that doctor’s, or that hospital’s, results to others. However it turns out that they are based on anecdotes, something that would be completely unacceptable in the reporting of scientific results. One expert noted that “There seems to be a disconnect between the business end of the cancer treatment industrial complex and the physicians on the front lines treating patients,” a dramatic understatement. “This isn’t retail advertising,” said the president of a Manhattan agency that developed ads for Mount Sinai hospital, “This is reputation advertising. There is a very big difference.”
Why hospitals want to advertise their cancer care (or their care for any other profitable “service line” such as, the article notes, cardiovascular disease or cosmetic surgery) is obvious – to make money. Though most of them are “not-for-profit”, all that means is that the “profits” don’t go to shareholders, but they can certainly be used by the hospital for expansion or creations of new and better service lines. And higher salaries and bonuses for executives (and physicians). Does it improve people’s health? Well, to a certain degree competition between hospitals does; like competition in any industry it operates against complacency, against “doing what we’ve always done”, against being satisfied with less than “the best”, because if it is possible to do better, there is the chance that your competitor will do better, and take away your business. It is also reasonable to advertise, so that people know how well you are doing. However, when the advertising is not based on real outcomes data, but purports to be, that is, it indicates – possibly not knowingly untruthfully but without evidence to back it up – that is at best misleading, and possibly unethical.
From a health perspective, a community needs a certain capacity for care of cancer patients – or any patients. That community may be a part of a city, or a city, or a metropolitan area, or in the case of rarer cancers, a region or even the nation. Excess capacity is extremely costly – if hospital A gets most of the cancer “business” in town, so hospital B chooses to invest heavily in building a new cancer-treatment facility (including, by the way, with public funds, since because they are not-for-profit, donations are philanthropy and tax-deductible), we now have excess capacity in the community, and a great deal of extra cost. To the extent that this represents a competition that results in better care, as discussed above, it may be a good thing – but the hospitals should have to document that there is actually better care provided, something almost never done. And, if it is going to spend a lot of money to create excess capacity in the community, the hospital should have to use the traditional method of raising capital and not be able to use tax-deductible contributions for this purpose (but, of course, they do).
There is another problem, which I mentioned briefly above. Hospitals do not heavily (and possibly deceptively) advertise all their services; like other businesses they advertise the profitable services. In general, services (“product lines”) are profitable because the current payment system reimburses for these services far more than the cost of delivering them. Cancer is in this category, because of the enormous markups for providing chemotherapy drugs (this is in addition to the enormous markups charged by the manufacturers). So are cardiovascular procedures, neurosurgical procedures, and of course cosmetic surgery. Hospitals do not heavily advertise the care that they provide (even if it is in fact excellent and better than others’ based on real data) if they don’t make as much, or even lose, money. This includes “regular” medical diseases, as well as very costly special services including much trauma and burn care. Pediatrics is a special case; in general (other than, of course, pediatric cancer care, for the same reasons as adult cancer care, and neonatal intensive care) does not make money, so general hospitals don’t heavily advertise it. “Children’s Hospitals”, however, are often among the greatest recipients of philanthropy in a community, and this is their main source of revenue, so advertising what they do makes sense for them in order to keep their name in front of donors.
We have become used to hearing (including from me) cautions about the greed and influence of the health insurance and the pharmaceutical and device manufacturers on health care, on health legislation and on politicians. These companies are for-profit and interested in their bottom lines, not on the impact that they have on health itself. Much of this is discussed in the New York Times article Health Lobby takes fight to the states on December 29, 2009, but as I have noted, it is the health care industry lobby, not the health lobby. We would have hoped that our communities’ hospitals would see themselves as more interested in our health, but this sort of advertising makes it clear that, non-profit though they may be, they are the health care industry.
Where does this leave us? It leaves us with the need to develop, and publicly report, good measures of outcomes for physicians and hospitals, as called for by many experts, notably Institute for Healthcare Improvement director Don Berwick, MD[1]. Otherwise people will continue to choose hospitals and doctors based on reputation and the quality of their “hotel facilities” rather than on the quality of their care. Pending that, we need to remember to see all health care advertising, including that from doctors and hospitals, as precisely that, advertising, and not confuse those claims with the scientific evidence that we hope will guide our care.
[1] Berwick, D., “Measuring physicians’ quality and performance: adrift on Lake Wobegon”, JAMA Dec9,2009;301:2485-6
.
Monday, January 11, 2010
Health Workers and the Afghanistan-Pakistan War
.
This is a guest blog by Seiji Yamada, MD.
President Obama has set our nation on the course of escalation of our war in Afghanistan-Pakistan. What should be the concerns of health workers in this current juncture? As health workers, we should concern ourselves with the health and human rights implications of the war that our nation is conducting. For one, we should care about what happens to the Afghan people, whose life expectancy is 45 years for women and 47 years for men. It is our responsibility as Americans to care about what happens to Afghan people in the course of this war that our nation has been waging since October 2001, particularly when they are injured or killed by our dint of American arms. The effects of war extends to consequences of war, such as the collapse of health services, lack of access to water and food, and damage to infrastructure, economies, and societies. We should keep in mind that Afghanistan is a country that has had ongoing conflict and civil turmoil since 1979.
As noted by Rubenstein and Newbrander, primary care services ensured by the Afghan Ministry of Public Health have improved since 2002:
[T]he number of health facilities has doubled and the number of trained midwives quadrupled. The share of health facilities with at least one female health worker has climbed to 83 percent. The number of children dying in infancy or before age 5 has declined nearly 25 percent, which translates into nearly 100,000 fewer infants and children dying this year, compared with 2002.
These initiatives have strengthened the foundations of a state that can serve its people. Rather than providing or contracting for services directly, USAID, the World Bank and the European Commission have strengthened the capacity of the Ministry of Public Health to develop and implement health policies, oversee programs, manage resources, engage communities and control the delivery of services. In contrast to the corruption obvious elsewhere, the health ministry has shown a level of transparency and accountability that allows U.S. funds to flow directly to the government for the provision of basic health services.[1]
The Ministry of Public Health defined a basic package of health services, including immunization, prenatal and obstetrical care, family planning, and care for childhood illnesses. The Ministry contracts with NGOs (27% of which are international NGOs) to deliver the basic package to a specified geographic area.[2]
In an October 5 CNN joint interview, Robert Gates and Hillary Clinton call for an increase in the proportion of American civilians to military involved in Afghanistan.[3] It is evident that they envision using agencies such as the US Agency for International Development (USAID) essentially as a "force multiplier" or the "hearts and minds" component of their military objectives in Afghanistan. The proposed director of the USAID, Rajiv Shah, a physician, tells the Senate Foreign Relations Committee, “If confirmed, I look forward to working with this Committee and my colleagues at USAID and the State Department to assess USAID’s contribution to counterinsurgency and stabilization operations.”[4]
Rubenstein and Newbrander note that the Washington is planning to divert USAID funding to “quick-impact” projects such as building health facilities or providing medical equipment in direct support of military operations:
Yet there is no evidence that expensive "quick impact" health projects that are not integrated into a larger strategy, or that do not actively engage locals, either contribute to security or wean populations from the enemy.
Quick-impact projects, such as clinic construction or the provision of new medical equipment, are rarely sustainable and seldom based on the community engagement needed for long-term effects. These simplistic and immediate interventions have been known to backfire. One military health analyst has criticized "drive-by" health interventions as "Band-Aid" operations that raise -- and then crush -- local expectations and ultimately lead to greater dissatisfaction and distrust. Moreover, as resources are diverted from the Afghan-led effort to build a system of effective and responsive primary care services, the emergence of a legitimate state will be compromised.[5]
Health workers should resist such attempts to co-opt the humanitarian community. Association with the military gives people the impression that humanitarian workers are furthering military objectives or U.S. foreign policy – threatening the security of aid workers and those that they are trying to assist.[6] Furthermore, health workers should refuse to participate in counterinsurgency.
On October 18, the New York Times Magazine ran a sympathetic story on General Stanley McChrystal’s plans for turning the war around in Afghanistan.[7] Under the rubric of counterinsurgency, the plans are to clear areas of Taliban by force of arms, then maintain control long enough (on the order of years) to reconstruct so-called “civil society.” By this is meant the elimination of corruption, the establishment of good governance, the rebuilding of infrastructure, schools, health care, economic development, the elimination of poppy cultivation, and so on.
In Iraq, McChrystal’s role was as commander of Joint Special Operations, ie.e, overseeing Delta Force and Navy SEALs in covert ops such as the killing the leader of al Qai’da in Iraq, al-Zarqawi, by bomb strike. In Afghanistan, however, McChrystal now upbraids a subordinate European general for bombing a target that might cause harm to civilians. Indeed, limiting the use of artillery and airstrikes reflects a recognition that they alienate the populace. As Vietnam, winning the “hearts and minds” of the Afghan population is the current logic.
But watching these counterinsurgency principles on display in the Frontline episode “Obama’s War”,[8] in which Marines are shown trying to convince villagers in Helmand Province to come shop at a market under U.S. control, it is evident that they are making little headway. Well-meaning though they may be, it is nevertheless painful to watch Marines try to be goodwill ambassadors. As noted by retired Marine John Bernard, who is critical of the rules of engagement that he believes led to the death of his son, Lance Corporal Joshua Bernard on August 14 in Helmand Province, Marines are not trained to be police officers and nation-builders, but rather to “kill people and break things.”[9] Indeed, a July 2006 survey, 3 years into the U.S. invasion of Iraq, estimated 655,000 Iraqi deaths as a consequence of war.[10] Our recent experience in Iraq should make it abundantly evident that the U.S. military is not adept at reconstructing civil society.
Secondly, let us consider unmanned aerial vehicle strikes in the Federally Administered Tribal Areas of Pakistan, the FATA. The CIA is conducting a program targeting Al-Qaeda leaders and enemies of the Pakistani government with missiles launched from unmanned aerial vehicles (UAVs) with names such as Predator and Reaper.[11] In conjunction with the surge of troops in Afghanistan, the Obama administration is stepping up these attacks. Although an unnamed U.S. government official claims that only 20 or so civilians have been killed,[12] Pakistani sources report that of 701 people killed in 60 attacks between January 2008 and April 2009, only 14 were suspected militants.[13] To assassinate Pakistani Taliban leader Baitullah Mehsud on August 5, 2009, sixteen missiles were launched over fourteen months, resulting in between 207 and 321 additional deaths.[14]
Why are such air attacks on civilians not considered war crimes? Air attacks are not as accurate as they are portrayed on TV. They often kill non-combatants, including women and children. Homes and neighborhoods, shelter, water and sanitation, people’s sources of livelihood, are destroyed. In military parlance, this is called merely “collateral damage”, but it is the lives of people and the infrastructure of society. We should also recognize that this bombing from the air turns people against those that they (correctly) hold responsible – the US military.[15] In the wake of the drone attacks on the Pakistani borderland with Afghanistan, an August 2009 Gallup poll revealed that 59% of Pakistanis perceive the U.S. as the biggest threat to Pakistan, compared to 18% who named India and 11% the Taliban.[16] The Pakistani newspaper Dawn reports that Peshawar residents hold the U.S. responsible for bombings that the Pakistani government attributes to the Taliban.[17]
Finally, because we still often resist realizing that we live in an empire, we miss the implications of that fact. I was taken by the title of Seth Jones’ book In the Graveyard of Empires.[18] Jones urges caution in Afghanistan, where attempts at conquest from Alexander the Great to the British and Soviet Empires met ignominious fates. But, a number of chapters into the book, I realized that Jones himself did not think of the U.S. as being an empire. The RAND political scientist has a plan for the U.S. to conduct counterinsurgency more effectively.
Is it incorrect, then, to consider the US an empire? Politically, in some respects, the U.S. remains one nation among many, such as in the UN General Assembly. In the economic realm, it competes with Europe and Asia. In the military realm, however, it reigns supreme. The tendency is thus for the U.S. to “lead with its strength,” choosing to resolve conflicts by military threat or attack.
In the words of Afghan women leading a recent protest against government corruption, "The innocent and oppressed people will be the victims of American air and ground attacks."[19] . As Americans, we are responsible for our nation’s actions around the globe. As health workers, we must uphold the cause of health worldwide. What should be our role be?
[1] Rubenstein LS, Newbrander W. Undermining Afghan health care. Washington Post, Nov 29, 2009. Accessed Dec. 12, 2009 http://www.washingtonpost.com/wp-dyn/content/article/2009/11/27/AR2009112702454_pf.html
[2] Loevinsohn B, Sayed GD. Lessons from the health sector in Afghanistan. JAMA 2008;300:724-726.
[3] Gates R, Clinton H. Interview. CNN, Oct 5, 2009. Accessed Dec 12, 2009 http://transcripts.cnn.com/TRANSCRIPTS/0910/06/ampr.01.html
[4] Questions for the Record Submitted for the Nomination of Rajiv Shah to be USAID Administrator by Senator John F. Kerry (#1) Senate Foreign Relations Committee. Accessed Dec 12, 2009 http://www.usglc.org/USGLCdocs/Shah_Responses_to_Kerry_QFR.pdf
[5] Rubenstein & Newbrander.
[6] Bristol N. Military incursions into aid work anger humanitarian groups. Lancet 2006;367:384- 386.
[7] Filkins D. Stanley McChrystal’s Long War. New York Times Magazine, Oct 18, 2009.
[8] Gaviria M, Smith M. Obama’s War. Accessed Nov 2, 2009 http://www.pbs.org/wgbh/pages/frontline/obamaswar/
[9] Sharp D. Marine’s dad speaks out. Honolulu Advertiser, Oct 18, 2009.
[10] Burnham G, Lafta R, Docey S, Roberts L. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Lancet. 2006; 368: 1421–28.
[11] Mayer J. The predator war. New Yorker, Oct 26, 2009. Accessed Nov 8, 2009 http://www.newyorker.com/reporting/2009/10/26/091026fa_fact_mayer
[12] Shane S. C.I.A. to expand use of drones in Pakistan. New York Times. Dec. 4, 2009. Accessed Dec 12, 2009 http://www.nytimes.com/2009/12/04/world/asia/04drones.html?hp
[13] Ahmad MI. Pakistan creates its own enemy. Le Monde Diplomatique. Nov 2009. Accessed Nov 5, 2009 http://mondediplo.com/2009/11/02pakistan
[14] Mayer J.
[15] Young M, Sprey P. (Interview). Bill Moyers Journal. Accessed Nov 2, 2009. http://www.pbs.org/moyers/journal/01302009/watch.html
[16] Ahmad MI.
[17] Bombings, drone attacks fuel anti-US sentiment in Pakistan. Dawn. Dec 7, 2009. Accessed Dec 12, 2009 http://www.dawn.com/wps/wcm/connect/dawn-content-library/dawn/news/pakistan/07-bombings-drone-attacks-fuel-anti-us-sentiment-in-pakistan-ha-02
[18] Jones S. In the graveyard of empires. New York: W.W. Norton, 2009.
[19] Perry T. Afghan women lead protest against government corruption. LA Times. Dec 10, 2009. Accessed Dec 12, 2009
http://www.latimes.com/news/nation-and-world/la-fg-afghanistan-protest11-2009dec11,0,320839.story
.
This is a guest blog by Seiji Yamada, MD.
President Obama has set our nation on the course of escalation of our war in Afghanistan-Pakistan. What should be the concerns of health workers in this current juncture? As health workers, we should concern ourselves with the health and human rights implications of the war that our nation is conducting. For one, we should care about what happens to the Afghan people, whose life expectancy is 45 years for women and 47 years for men. It is our responsibility as Americans to care about what happens to Afghan people in the course of this war that our nation has been waging since October 2001, particularly when they are injured or killed by our dint of American arms. The effects of war extends to consequences of war, such as the collapse of health services, lack of access to water and food, and damage to infrastructure, economies, and societies. We should keep in mind that Afghanistan is a country that has had ongoing conflict and civil turmoil since 1979.
As noted by Rubenstein and Newbrander, primary care services ensured by the Afghan Ministry of Public Health have improved since 2002:
[T]he number of health facilities has doubled and the number of trained midwives quadrupled. The share of health facilities with at least one female health worker has climbed to 83 percent. The number of children dying in infancy or before age 5 has declined nearly 25 percent, which translates into nearly 100,000 fewer infants and children dying this year, compared with 2002.
These initiatives have strengthened the foundations of a state that can serve its people. Rather than providing or contracting for services directly, USAID, the World Bank and the European Commission have strengthened the capacity of the Ministry of Public Health to develop and implement health policies, oversee programs, manage resources, engage communities and control the delivery of services. In contrast to the corruption obvious elsewhere, the health ministry has shown a level of transparency and accountability that allows U.S. funds to flow directly to the government for the provision of basic health services.[1]
The Ministry of Public Health defined a basic package of health services, including immunization, prenatal and obstetrical care, family planning, and care for childhood illnesses. The Ministry contracts with NGOs (27% of which are international NGOs) to deliver the basic package to a specified geographic area.[2]
In an October 5 CNN joint interview, Robert Gates and Hillary Clinton call for an increase in the proportion of American civilians to military involved in Afghanistan.[3] It is evident that they envision using agencies such as the US Agency for International Development (USAID) essentially as a "force multiplier" or the "hearts and minds" component of their military objectives in Afghanistan. The proposed director of the USAID, Rajiv Shah, a physician, tells the Senate Foreign Relations Committee, “If confirmed, I look forward to working with this Committee and my colleagues at USAID and the State Department to assess USAID’s contribution to counterinsurgency and stabilization operations.”[4]
Rubenstein and Newbrander note that the Washington is planning to divert USAID funding to “quick-impact” projects such as building health facilities or providing medical equipment in direct support of military operations:
Yet there is no evidence that expensive "quick impact" health projects that are not integrated into a larger strategy, or that do not actively engage locals, either contribute to security or wean populations from the enemy.
Quick-impact projects, such as clinic construction or the provision of new medical equipment, are rarely sustainable and seldom based on the community engagement needed for long-term effects. These simplistic and immediate interventions have been known to backfire. One military health analyst has criticized "drive-by" health interventions as "Band-Aid" operations that raise -- and then crush -- local expectations and ultimately lead to greater dissatisfaction and distrust. Moreover, as resources are diverted from the Afghan-led effort to build a system of effective and responsive primary care services, the emergence of a legitimate state will be compromised.[5]
Health workers should resist such attempts to co-opt the humanitarian community. Association with the military gives people the impression that humanitarian workers are furthering military objectives or U.S. foreign policy – threatening the security of aid workers and those that they are trying to assist.[6] Furthermore, health workers should refuse to participate in counterinsurgency.
On October 18, the New York Times Magazine ran a sympathetic story on General Stanley McChrystal’s plans for turning the war around in Afghanistan.[7] Under the rubric of counterinsurgency, the plans are to clear areas of Taliban by force of arms, then maintain control long enough (on the order of years) to reconstruct so-called “civil society.” By this is meant the elimination of corruption, the establishment of good governance, the rebuilding of infrastructure, schools, health care, economic development, the elimination of poppy cultivation, and so on.
In Iraq, McChrystal’s role was as commander of Joint Special Operations, ie.e, overseeing Delta Force and Navy SEALs in covert ops such as the killing the leader of al Qai’da in Iraq, al-Zarqawi, by bomb strike. In Afghanistan, however, McChrystal now upbraids a subordinate European general for bombing a target that might cause harm to civilians. Indeed, limiting the use of artillery and airstrikes reflects a recognition that they alienate the populace. As Vietnam, winning the “hearts and minds” of the Afghan population is the current logic.
But watching these counterinsurgency principles on display in the Frontline episode “Obama’s War”,[8] in which Marines are shown trying to convince villagers in Helmand Province to come shop at a market under U.S. control, it is evident that they are making little headway. Well-meaning though they may be, it is nevertheless painful to watch Marines try to be goodwill ambassadors. As noted by retired Marine John Bernard, who is critical of the rules of engagement that he believes led to the death of his son, Lance Corporal Joshua Bernard on August 14 in Helmand Province, Marines are not trained to be police officers and nation-builders, but rather to “kill people and break things.”[9] Indeed, a July 2006 survey, 3 years into the U.S. invasion of Iraq, estimated 655,000 Iraqi deaths as a consequence of war.[10] Our recent experience in Iraq should make it abundantly evident that the U.S. military is not adept at reconstructing civil society.
Secondly, let us consider unmanned aerial vehicle strikes in the Federally Administered Tribal Areas of Pakistan, the FATA. The CIA is conducting a program targeting Al-Qaeda leaders and enemies of the Pakistani government with missiles launched from unmanned aerial vehicles (UAVs) with names such as Predator and Reaper.[11] In conjunction with the surge of troops in Afghanistan, the Obama administration is stepping up these attacks. Although an unnamed U.S. government official claims that only 20 or so civilians have been killed,[12] Pakistani sources report that of 701 people killed in 60 attacks between January 2008 and April 2009, only 14 were suspected militants.[13] To assassinate Pakistani Taliban leader Baitullah Mehsud on August 5, 2009, sixteen missiles were launched over fourteen months, resulting in between 207 and 321 additional deaths.[14]
Why are such air attacks on civilians not considered war crimes? Air attacks are not as accurate as they are portrayed on TV. They often kill non-combatants, including women and children. Homes and neighborhoods, shelter, water and sanitation, people’s sources of livelihood, are destroyed. In military parlance, this is called merely “collateral damage”, but it is the lives of people and the infrastructure of society. We should also recognize that this bombing from the air turns people against those that they (correctly) hold responsible – the US military.[15] In the wake of the drone attacks on the Pakistani borderland with Afghanistan, an August 2009 Gallup poll revealed that 59% of Pakistanis perceive the U.S. as the biggest threat to Pakistan, compared to 18% who named India and 11% the Taliban.[16] The Pakistani newspaper Dawn reports that Peshawar residents hold the U.S. responsible for bombings that the Pakistani government attributes to the Taliban.[17]
Finally, because we still often resist realizing that we live in an empire, we miss the implications of that fact. I was taken by the title of Seth Jones’ book In the Graveyard of Empires.[18] Jones urges caution in Afghanistan, where attempts at conquest from Alexander the Great to the British and Soviet Empires met ignominious fates. But, a number of chapters into the book, I realized that Jones himself did not think of the U.S. as being an empire. The RAND political scientist has a plan for the U.S. to conduct counterinsurgency more effectively.
Is it incorrect, then, to consider the US an empire? Politically, in some respects, the U.S. remains one nation among many, such as in the UN General Assembly. In the economic realm, it competes with Europe and Asia. In the military realm, however, it reigns supreme. The tendency is thus for the U.S. to “lead with its strength,” choosing to resolve conflicts by military threat or attack.
In the words of Afghan women leading a recent protest against government corruption, "The innocent and oppressed people will be the victims of American air and ground attacks."[19] . As Americans, we are responsible for our nation’s actions around the globe. As health workers, we must uphold the cause of health worldwide. What should be our role be?
[1] Rubenstein LS, Newbrander W. Undermining Afghan health care. Washington Post, Nov 29, 2009. Accessed Dec. 12, 2009 http://www.washingtonpost.com/wp-dyn/content/article/2009/11/27/AR2009112702454_pf.html
[2] Loevinsohn B, Sayed GD. Lessons from the health sector in Afghanistan. JAMA 2008;300:724-726.
[3] Gates R, Clinton H. Interview. CNN, Oct 5, 2009. Accessed Dec 12, 2009 http://transcripts.cnn.com/TRANSCRIPTS/0910/06/ampr.01.html
[4] Questions for the Record Submitted for the Nomination of Rajiv Shah to be USAID Administrator by Senator John F. Kerry (#1) Senate Foreign Relations Committee. Accessed Dec 12, 2009 http://www.usglc.org/USGLCdocs/Shah_Responses_to_Kerry_QFR.pdf
[5] Rubenstein & Newbrander.
[6] Bristol N. Military incursions into aid work anger humanitarian groups. Lancet 2006;367:384- 386.
[7] Filkins D. Stanley McChrystal’s Long War. New York Times Magazine, Oct 18, 2009.
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[9] Sharp D. Marine’s dad speaks out. Honolulu Advertiser, Oct 18, 2009.
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[11] Mayer J. The predator war. New Yorker, Oct 26, 2009. Accessed Nov 8, 2009 http://www.newyorker.com/reporting/2009/10/26/091026fa_fact_mayer
[12] Shane S. C.I.A. to expand use of drones in Pakistan. New York Times. Dec. 4, 2009. Accessed Dec 12, 2009 http://www.nytimes.com/2009/12/04/world/asia/04drones.html?hp
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[14] Mayer J.
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[19] Perry T. Afghan women lead protest against government corruption. LA Times. Dec 10, 2009. Accessed Dec 12, 2009
http://www.latimes.com/news/nation-and-world/la-fg-afghanistan-protest11-2009dec11,0,320839.story
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Thursday, January 7, 2010
Primary Care and Residency Expansion
In discussing some of the things I liked in the bill that passed the Senate (December 23, 2009, Health Reform: The good, the bad, and the bigoted ) one of them was that the proposal to expand by 15,000 the number Medicare-supported residency (or Graduate Medical Education, GME) positions did not get included. The reason was that it did not explicitly require that these positions be used for primary care, which I believe is an essential requirement. I cited the strong arguments made by Shannon Brownlee and David Goodman in their New York Times op-ed of the same date, "Doctors no one needs". Most primary care, and particularly family medicine, groups were also unenthusiastic to opposed.
The Association of American Medical Colleges (AAMC) does not agree, unsurprisingly to those who are familiar with medical education, and was the biggest advocate for that provision. As AAMC President Darrell Kirch wrote in his December 21, 2009 communication “Leader to Leader” (not publicly available on the AAMC website), the news on the Senate bill “…was a great disappointment because we viewed this as a truly historic opportunity to make a positive impact on our future workforce.” In what many in the primary care community saw as a more combative statement, he went on to say “During this process we were deeply concerned that some members of the primary care community spoke out against the amendment, and argued that it would not support the expansion of the primary care workforce. Facing an extremely tight timetable, Senate staff clearly indicated to us that such opposition would discourage the leadership from moving forward on any GME language. The AAMC expressed strong concern that the vocal opposition of the family medicine community threatened to halt progress on GME legislation that did indeed benefit all training programs.”
In a recent letter to Senator Harry Reid, staking out the organization’s positions on what needs to be included (read “benefits academic medicine”) as the Senate and House move to reconcile their health bills in conference, Dr. Kirch writes that the GME expansion is critical, and that the AAMC is “…supporting the inclusion of this workforce expansion as part of provisions to strengthen primary care.” That sounds, good, making nice. However, other parts of the letter indicated that AAMC’s attack on primary care, and particularly family medicine, groups, for not supporting the its agenda of expanding (“benefit[ing] all training programs”) has progressed.
"The AAMC recognizes that primary care is an integral part of health care delivery. Primary care, however, may be provided by many types of physicians and other practitioners. We support defining primary care by the types of services provided and not by a specialty of the physician or other provider.”
What is the problem here? Surely the assertion above is reasonable, that defining primary care by services provided rather than the specialty of the provider makes sense. And the AAMC is saying it is supportive of primary care, and even including goals for more residents in the primary care specialties in the expansion of GME slots. It is a big step for the AAMC to be so supportive, publicly, of primary care, as they have not always been. And, in addition, there are other specialty areas (e.g., general surgery) that are also in great shortage. Indeed, the movement has been to sub-specialization and sub-sub-specialization, so we are seeing fewer physicians who are even generalists in their own sub-specialties (such as cardiology). The goal should definitely not be to increase slots only for primary care, but to target those specialties in which there is a mismatch between the number of doctors being trained and the number needed by the community.
Considering primary care, however, there are several problems with the current AAMC proposal.
1. The proposed bill is about expanding residency slots, not about defining the content of a primary care practice. Yes, there are subspecialists who provide comprehensive patient-centered care for their patients. Particularly in pediatrics, but also in adult internal medicine; people who have mainly one serious chronic disease (kidney failure, cancer, heart disease) sometimes receive most of their comprehensive care from nephrologists, oncologists, or cardiologists (more often in pediatrics because having only one chronic disease is the norm in children, but much less common in adults). Many of these subspecialists do not. In identifying practices as providing primary care for, say, increased reimbursement, looking at services provided is quite reasonable. However, in looking at a strategy for creating greater primary care capacity, what makes sense is to expand the residency programs in specialties that are particularly about training physicians to practice primary care, and whose graduates actually do so – family medicine, general pediatrics, and general internal medicine. This is especially true when looking at how we can provide comprehensive primary care to communities, not simply to selected individuals. To say “let’s just train more doctors altogether, and some will probably do some primary care" (radiologists? anesthesiologists? ophthalmologists?) is a nonsense strategy.
2. The significant impact on the health of the population that is related to increased primary care capacity only occurs with more primary care doctors. It does not occur with just more doctors, some of whom might do some primary care. (This is the point of the Brownlee and Goodman piece cited above.) These results have been documented repeatedly, in a variety of geographic areas and populations. Yes, there is also a contribution made by “non-physician” primary care providers including nurse practitioners and physician’s assistants, but they are not the concern of the AAMC, and, moreover, are increasing not practicing primary care. (See “myths” 2 & 3 in Dr. Bowman’s guest blog of January 15, 2009, Ten Biggest Myths Regarding Primary Care in the Future.) I addressed the issue of specialty choice in More Primary Care Doctors or Just More Doctors? (April 3, 2009). Of note, Dr. Richard Cooper, whose positions I criticize in that piece, has more recently been advocating for the needs of poor and minority communities, a good thing. His main point is that the Dartmouth Atlas data on geographic variation do not account for socioeconomic differences (debatable, certainly); however, I have not seen any retraction of his AAMC-type support for “more doctors” rather than more primary care doctors.
3. There are not enough students currently interested in entering primary care to fill currently existing positions. Thus, even if a greater priority were given to family medicine and other primary care residency positions, the new positions would, barring a major change – that would, as discussed in many previous pieces, have to be systemic and involve large, not simply cosmetic, changes in reimbursement – also be unfilled, at least by US graduates. Then, of course, the teaching hospitals and medical schools would use them for other specialties. Indeed, a big reason even more students do not enter the “ROAD” specialties described by Pauline Chen (“Primary Care’s Image Problem”, New York Times November 12, 2009, and discussed in this blog November 17, 2009, as Primary Care’s Image: A Problem?) is the limited number of slots; increasing slots without increasing the attractiveness of primary care as a career option will just increase the mismatch between the proportion of primary care doctors needed by the society and that being produced by medical schools. To the extent that primary care residency positions are filled by international medical graduates, it continues to contribute to the “brain drain”, where third-world countries bear the cost of educating physicians to provide care to first-world citizens.
In greater detail, Patrick Dowling, chair of family medicine at UCLA, comments on the AAMC letter:
“Granted these are complex issues but in the end I read this as: ‘give us more of the same—we need more doctors, more funding for academic centers and we need to get reimbursed better!’ I think the AAMC would have much more credibility if they stepped up to the plate and said:
‘The US health care delivery system is terribly flawed and we are a significant part of the problem. We have terrible geographic and specialty maldistribution of physicians, our costs continue to be way out of line compared to any other industrialized country and we have unacceptable racial and ethnic disparities in outcomes of care.
‘Moreover, because the graduates of our medical schools have overwhelming chosen to practice subspecialty medicine in green leafy suburbs we must import international physicians, to staff our inner cities and rural towns in exchange for visas. Although we are fortunate to have someone to send, these docs face overwhelming linguistic and cultural barriers, especially in the provision of care to low income minority populations. And in some instances they represent a “brain drain” in from the donor countries
‘Further, as the baby boomers begin to hit age 65 at the rate of 5,000 per day on Jan 1, 2011, the epidemic of chronic diseases linked to aging will soar. We would propose the following new innovative steps to insure that we have a geographically dispersed physician workforce that delivers cost effect, high quality care with a physician workforce that is optimally balanced by specialty.
‘If you provide $X billion in extra funding for Academic Medical Centers (AMCs), enhanced funding for NIH budgets and thousands of more Medicare funded GME spots we will insure that the number of HPSAs will be reduced by X, that the actual number of USMGs choosing bona fide primary care specialties will increase by Y number which will result in a primary care to specialty ration of A to B, a ratio which works very well in other industrialized democracies.
‘Finally, if we are funded we promise to bend the unacceptable curve of increasing costs so that average yearly increases are less than X% of CPI. If we fail to meet these objectives we agree to decreased funding over the following years of $Z billion.’
“If I was in the US Congress,” Dr. Dowling concludes, “I would tell the AAMC that rather than stuffing their pockets it is time to put some skin in the game and actually become the leaders in the science of health care delivery and solve these problems.”
Hear, hear.
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