Comparative Effectiveness Research
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The Prescription for Revolutionary Healthcare Delivery Reform
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Army of Women Aims to Eradicate Breast Cancer
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Whistleblowers Expose Hospitals Fleecing the Public's Back
What Is the Public Option?
Published September 06, 2009 @ 05:51PM PT
The public option has become the central front in the fight for health care reform. It’s become a litmus test on the left and the right, with the House Progressive Caucus saying they won’t vote for a reform bill that omits it, and with Republicans generally united against it, even one with a delay or a trigger that would kick its implementation down the road. It’s been discussed almost constantly since February 2007 when John Edwards made it part of his health care plan, with both Barack Obama and Hillary Clinton soon following suit. It’s become a proxy fight for health care reform in general. But for all that, many people are still confused as to what it is, who would have access to it, or why it might be a good idea in the first place.
It is not, in and of itself, the entirety of the health care reform proposal in Congress, or what President Obama proposed on the campaign trail as a fix for our broken health care system. Reform encompasses everything we need to do to finally begin controlling our health care costs, expanding access and improving quality. All three of these goals are the focus of the House bill (HR 3200) and the Senate Health, Education, Labor and Pensions Committee.
The moving parts of this bill covers an incredibly wide gamut of issues, from developing new doctors and new nurses, particularly in primary care; to giving tax credits to small businesses in order to allow them to afford benefits for their employees; to filling in the “doughnut hole” in the Medicare prescription drug program to provide cheaper drugs to seniors; to creating regulation or prevent or curb the most abusive practices of the insurance industry.
The House bill is 1,018 pages long and the whole package is estimated to cost $1 trillion over 10 years -- all or most of which is already paid for by savings and new revenue earmarked in the bill. But the whole package is not “the public plan” or the “public option.” Of the 1,018 pages, only 12 of them deal with the establishment of a public health insurance option.
Preventative Care Requires Smarts and Time But Does Save Money
Published September 03, 2009 @ 08:03PM PT
It was an ominous Washington Post headline that greeted me this morning: “Study Raises Questions About Cost Savings From Preventive Care.” Is this the precursor to a wave of stories about how preventative care doesn’t save money anyway so we shouldn’t even bother? It would be a shame if true, since the article in Health Affairs shows that there are some considerable savings to be had -- if we apply the finds with some intelligence and some patience.
Everyone who’s serious about health care, Republican and Democrat, sings the praises of prevention -- of transforming the way we practice medicine to prevent illnesses from occurring in the first place, rather than focus on expensive treatments to pay for advanced care. But although it's easy to sell as a Platonic ideal, it's hard for a specific progra, to make it into a spending bill. For one thing, once you actually have a dollar amount for diabetes prevention, smoking cessation, HIV prevention and what have you in front of you, someone is suddenly willing to make the case that these are the elements we can’t afford, that need to be trimmed, and that are nice-to-haves not need-to-haves for the final package. Oh we’re for prevention, we’re told, just not for this particular program. For another, the Congressional Budget Office generally scores within a 10-year budget window. But some of the most effective preventative care techniques yields savings beyond that window -- 20 to 25 years down the road. That makes it very easy to demagogue against “wasteful” preventative care -- sure, we’re told, things like cancer screening, cholesterol management and anti-obesity programs make people healthier, but they cost more than they save in 10 years.
It was an attempt to prove this theory of long-term savings that the authors began their study of patients who had been diagnosed with Type-2 diabetes. Washington Post, hyping the controversy, delivers this assessment, “However, except for the youngest diabetics, the additional services would add to overall health spending, not decrease it, the study shows.” But, er, that’s a pretty big exception. In fact, the group aged 24-30 saved $6 billion dollars out of their projected medical costs over a 25-year window. As Merrill Goozer of Gooz News sees it, “If anything, this study was a strong argument for targeting this particular prevention strategy to only the very young or those on the cusp of going into Medicare. Too bad it wasn't presented that way.”
No, prevention isn’t a magic wand or a magic cost-saver. But done intelligently, and targeted for the best effect and with a long-view, the savings are real. Despite what the Washington Post says, the study didn't raise questions -- it helped answer them.
(Photo credit: Sarah G... on Flickr.)
Health Care Savings in CBO Mirror Are Larger Than They Appear
Published August 26, 2009 @ 11:24PM PT
The Congressional Budget Office is the “umpire” for legislation moving through Congress, including health care. But they’re not staffed by Nostradamus. An Op-Ed in today’s New York Times reminds us, their predictions about savings and costs for health care provision have a bad habit of being quite wrong.
What do I mean by calling the CBO the “umpire”? Anyone proposing legislation, be they Republican or Democrat, must have their bill scored by the non-partisan battery of accountants and economists, who will report on a.) whether the bill is “paid for” or not, and b.) if it’s not paid for, by how much will it increase the deficit. You can either pay for a bill by creating new revenue or by achieving savings. Of course, proponents of the bill will always tell you proposed savings are a sure thing while opponents of the bill will accuse the authors of being unrealistically optimistic. The CBO’s role, then, is critical – whatever numbers they score the legislation at, that’s the number both sides have to use, whether they like it or not.
But much like the use of an instant-replay “pitch tracker” on baseball TV broadcasts has made us all aware of how often umpires get the call wrong, so the Op-Ed by Jon Grabel of the University of Chicago. His thesis: “In each of the past three decades, when assessing major changes in Medicare, it has substantially underestimated the savings the changes would bring.”
- In the 1980s, a change in the way Medicare reimbursed hospital admissions was supposed to be $10 billion over 3 years. Instead, the savings in 1986 alone were $11 billion.
- In the 1990s, as part of the Balanced Budget Act of 1997, a change for reimbursement for skilled nursing facilities and home health care services, and new investments in fighting fraud in Medicare were supposed to yield modest savings. Instead, they “Medicare spending fell so much that Congress increased payment levels to hospitals and other providers in 1999 and 2000.”
- And of course in this decade, the CBO’s projection on increased costs through Medicare Part D’s prescription drug program have been spectacularly wrong – they overestimated by 40%.
Many are looking at the health care bills coming out of the House and the late Senator Kennedy’s committee through the lens of the CBO’s projections for savings. This is only natural, since long-term cost containment is a critical component of health care reform and a lot of the cost is tied up in investments like comparative effectiveness research, primary care, Health IT and other items that have dramatically brought down costs for the VA and other countries.
But don’t be dismayed if CBO seems to be low-balling the savings we can expect. If history is any guide, the savings in the mirror are closer than they appear.
(Photo credit: JoelZimmer on Flickr.)
Betsy McCaughey, Meet Jon Stewart
Published August 21, 2009 @ 08:11AM PT
Betsy McCaughey, the paid board member for medical device companies and former lieutenant governor of New York who has made her political career on doing “close readings” of health care legislation that scare the living bejeesus out of the general populace, was on Jon Stewart last night. Those with a low tolerance for flapdoodle should avoid the following:
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Exclusive - Betsy McCaughey Extended Interview Pt. 1
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Two observations:
This absolutely was not the medium for the McCaughey style of argument. In a 700 word editorial for the NY Post, she can make a claim, cite the bill, and explain what it “really means” without ever being asked to explain how her assertion relates to the original. Hence she’s able to take a provision that’s intended to make sure that end-of-life directives are followed (including, as Jon Stewart notes, if that directive is “keep me alive by any means necessary”) connect to people on Medicare being denied or delayed on hip surgeries, living in pain, etc. It becomes absolutely clear that her citations in the bill are a means to the end. What she really wants to talk about is the emotional fear of being denied the care you need when you’re in pain, something those of us with HMOs are all too familiar with but Medicare beneficiaries generally are not. Finding a small provision in a bill that most people agree with – heck, if I had an end-of-life directive and the doctor didn’t follow it, you bet I wouldn’t want him/her to get paid full price – and using a leap of logic to get to an unconnected fear works in print, but it doesn’t work when you have someone in front of you saying, “Wait, that’s not what this says.”
Second, this is “mushroom cloud” logic. It’s all absolutes where all cuts to Medicare have equal weight and you’re left with a stark choice – invade Iraq or have St. Louis nuked. It turns out that wasn’t the choice there, and it isn’t the choice here, either. Cutting overpayments to insurance companies for Medicare Advantage will result in denied profit margins, not denied care. Reducing a payment rate for MRIs which was set when we believed they’d be in use half of the time because we now realize they’re in use 80% of the time or more won’t lead to my grandmother being denied her MRI when she needs it. (Indeed, the worry I’ve heard is that it will cause doctors to prescribe even more MRIs, whether necessary or not).
But let’s give McCaughey a taste of her own medicine. In this clip, she doesn’t want to see Medicare get cut at all, or any treatment denied at any time, no matter the cost and no matter the evidence. She also wants, as she says, for the uninsured to be subsidized. So the question is why does McCaughey want us to devote the entirety of the federal budget to unlimited health care for the entire population at a time of war? If you never deny any care for any reason and cover everyone, as she suggests, clearly health care will jump from 20% to 50% of our budget next year. I love this country too much to see our Department of Defense downsized so radically during a time of increasing danger around the globe. What good will our unlimited MRIs for every age and health condition be when North Korea launches nuclear missiles against us?
Yes, this is preposterous logic. So is McCaughey’s.
The Best Government-Run Health Care of All
Published August 18, 2009 @ 11:49PM PT
First we had “keep your government hands off my Medicare.” But when you’re talking about the health care hospitals, clinics and doctors run by the Department of Veterans Affairs, the antecedent is true. Already this year, they have loudly proclaimed, “keep your private insurance hands off my VA.” Good thing the VA will continue to be run by the federal government, continuing to provide arguably the best care in the United States. In fact, as President Obama reminded us yesterday, the VA is in line for a major upgrade.
Medicare beneficiaries scared out of their wits that health care reform meant their own government-run health program would deteriorate have gotten a lot of coverage. Veterans have not, though it’s clear they share the same concerns. The Arizona Republic quotes Vietnam veteran Paul Susedo as saying, “It surprised me that he was so in favor of the veterans' benefits, because we had heard that they were planning to cut them.” Actually, that was the last guy. Nearly half a million so-called Priority 8 veterans lost their VA coverage during the Bush years. These are non-disabled vets who make more than $30,000/year, who are allowed to enter only if the VA projects it will have enough money. How do we know they can afford it this year? Because the Obama budget that passed months ago contains, in the words of the Christian Science Monitor, “the largest increase in funding in 30 years. The intent is to reduce waiting times for veterans seeking help, expand coverage, and hire more case managers to process claims.”
Why is the VA ramping up when we’re trying to cut the costs for the rest of health care? Because it’s already incredibly efficient. The system already negotiates for better drug rates than Medicare. VistA, the Health IT system developed by the VA, has been working well enough that it’s used as a launching point for other Health IT projects, but more importantly allows the VA to minutely track and adjust its quality and health outcomes, leading to results which outpace all other health care systems in the U.S., according to the RAND Corporation and the New England Journal of Medicine. As the RAND report specifically calls out, “The greatest differences between the two samples were in areas where the VA actively measured performance.”
We talk about “building on what works” and a “uniquely American system.” Usually that’s in reference to employer-based private insurance. But if we really want the best American health care money can buy, we need to focus on the central lesson of the VA: the status quo is never enough. We can always do even better.
(Photo credit: foreversouls on Flickr.)
Don't You Dare Take Away My Useless Placebo!
Published August 07, 2009 @ 10:09PM PT
NPR and the NY Times both ran stories about multiple newly-released studies that call into question the effectiveness of a longstanding treatment for the pain caused by osteoporosis. Not the comparative effectiveness – the effectiveness, period. Within the context of the wild rumors about what investing in comparative effectiveness research will or will not do to the quality of care, the studies couldn’t come at a better time. It’s not just the results themselves that show how badly we need to fund and learn from more of this research. It’s the reactions to that research by doctors and patients that is most revealing – and alarming!
Vertebroplasty was devised as a treatment for back pain caused by fractured vertebrae. Until 15 years ago, the options for treatment were limited to localized pain killers, rest, back braces, that sort of thing. But then, a researcher at the Mayo Clinic became the first American physician to injecting a type of cement into the damaged bone to reinforce it. The procedure is not without its flaws – an infrequent risk is that the cement will leak into the blood and damage vital organs, or that the cement in one or two vertebrae will lead to breaks in others. There’s also the cost -- $1,000 to $2,000 for an MRI, followed by $2,500 to $3,000 for the procedure. Still, it was quick, easy, and popular – patients usually reported relief from the pain, and 73,000 people had the procedure done last year alone. No problem, right?
Well, one big problem. Simultaneous studies in Australia, Great Britain and the U.S. showed that despite its popularity, it was no more effective than a placebo. Patients reported the same amount of pain relief from the procedure that costs thousands of dollars as they did from getting a simple Novocain injection and, in one of the surveys, being told that they were receiving the cement injection, without actually receiving it. As orthopedic surgeon Dr. James Weinstein summarized, “What it said to me is that essentially this is a treatment with no effect, and it probably shouldn't be done any more.” Dr. Rachelle Buchbinder, who participated in the test in Australia, was even starker in her assessment: “It does not work.”
Open and shut, right? After wall, it was confirmed in three different studies – including one designed by Dr. David Kallmes, the radiologist who first attempted the treatment at the Mayo Clinic.
Not so fast. This is American health care. We don’t make decisions based on effectiveness, let alone cost-effectiveness.
After all, vertebroplasty makes over $250 million a year for providers. Dr. Kallmes knew what this meant: “I’m going to be the most reviled radiologist on the planet.” Indeed, NPR writes this intriguing sentence: “The head of the North American Spine Society says the broken vertebrae studies show that both the placebo and cement procedures work.” Placebos work, at root, because we think they work. That’s how the NY Times is able to write about, “One patient in the study, Jeanette Offenhauser, 88, said she was convinced that the cement had helped her severe back pain, even after hearing the results.” But here's the thing, those of you wondering how much patient choice will be affected by this devious display of actual scientific research. Nowhere in the stories does it suggest that this research will become unavailable or even curtailed, or even that that's a possibility for the future. The most the doctors want is to be able to present the options – as in, if it’s a placebo anyway, you may wish to go for the cheaper option, or you should at least know that there’s no real evidence that the more expensive option works better.
As more and more negative ads and unruly shouters shriek about rationing, about denial of care, and about how we shouldn’t consider ever cutting a dime out of Medicare (despite those same people often going on to point how Medicare spending is out of control), it’s hard not to think the placebo effect is alive and well in politics, not just American medicine.
(Photo credit: damclean on Flickr.)
Krugman, Sarcasm and Soylent Green: The Best of the Weekend
Published August 02, 2009 @ 05:53PM PT
Every Sunday, I’ve taken to posting the best of the best – the three must-reads or must-watches that will really help you parse what’s going on. During the presidential campaign, we took to calling the period where the importance of what was covered was in inverse proportion to the frequency with which it was covered “silly season.” This week, the focus seemed to be on – well – beers at the White House. ‘Nuff said.
So here are the three weekend articles you won’t want to miss to remove some of the silliness from your coverage. As we move into August, the misinformation begins to fly. Most of it will be reported as “he says/she says” by the news – two sides of an argument that deserve equal weight. But as these writers show, there’s a big difference. One side is looking to address the problems of our broken health care system, and the other is trying to make it seem as confusing and hopeless as possible.
If there’s a silver lining, it’s that so many great writers are determined not to let the agents of the status quo have the last word.
1.) Paul Krugman – “Health Reform Made Simple”
I’ve lost track of the number of people who have asked why there can’t be a simple 2 page description of what’s going on in health care reform and then, when I start to explain it in as simple terms as I know how, stop me with questions that get both deep and technical. Of course, the deep, technical questions are how it’s supposed to be – participatory democracy should involve meat and not just baby food. But it does point out an interesting fact – it’s easy enough to debate health care reform in a couple of hours or in a 100-page document. It’s tough to debate it in a few minutes and 500 words.
But just as I comforted myself with that notion, Paul Krugman delivers the best and most succinct explanation of health care reform you can imagine. And yes, it’ll take you minutes to read:
The essence is really quite simple: regulation of insurers, so that they can’t cherry-pick only the healthy, and subsidies, so that all Americans can afford insurance. Everything else is about making that core work…
That’s it. Any commentator who whines that he just doesn’t understand it is basically saying that he doesn’t want to understand it.
Read the whole blog post here.
2.) Jonathan Alter, “What’s Not to Like?”
Satire is the art of turning a preposterous argument on its head to demonstrate its truly silly core. With this Newsweek article, subtitled “Reform? Why do we need health-care reform? Everything is just fine the way it is,” Alter undresses what is beginning to become a popular argument of saying the convoluted, wasteful, prohibitively expensive and abusive American health care system doesn’t need fundamental change. It’s an argument so at odds with the experience of most Americans when dealing with an illness or injury that it deserves what Alter gives it – sarcasm:
I had cancer a few years ago. I like the fact that if I lose my job, I won't be able to get any insurance because of my illness. It reminds me of my homeowners' insurance, which gets canceled after a break-in. I like the choice I'd face if, God forbid, the cancer recurs—sell my house to pay for the hundreds of thousands of dollars in treatment, or die. That's what you call a "post-existing condition."
I like the absence of catastrophic insurance today. It meant that my health-insurance plan (one of the better ones, by the way) only covered about 75 percent of the cost of my cutting-edge treatment. That's as it should be—face cancer and shell out huge amounts of money at the same time. Nice…
Speaking of fair, it seems fair to me that cost-cutting bureaucrats at the insurance companies—not doctors—decide what's reimbursable. After all, the insurance companies know best.
Read the whole article on Newsweek's site.
3.) The White Coat Underground, “Health Care Reform – How to Obfuscate, Confuse and Inflame”
I wasn’t following this blog but, after this post, it’s a must have on my RSS reader. PaulMD is an internist in the Great Lakes region, and he knows malarkey when he sees it. The new constant refrain (the new “socialized medicine is bad,” if you will) of those who would like to continue profiting financially and/or politically from the current inefficiencies of our health care system goes something like this: the government will overrule your doctor. The supposed villain is comparative effectiveness research. Well, it just so happens that PaulMD is a doctor. His diagnosis of this fear-mongering argument? It’s baloney:
How does [Betsy McCaughey] justify this unjustifiable conclusion? She doesn't. She simply asserts it. "Comparative effectiveness" is an au courant term used to describe research that looks at medical practices and tried to assess its effects. For example, there are two surgical ways to fix blood flow to the heart muscle: percutaneous coronary interventions (PCIs) such as angioplasty and stenting, and coronary artery bypass grafting (CABG or "heart bypass"). I'm not going to teel you which one is better, because the answer is complicated and still being investigated, but to choose the correct therapy for a patient we must answer a number of questions: which works best in which kind of patient; how long does each last; which has lower complication rates; which leads to longer survival; which leads to longer survival without additional need for a second intervention; which costs more, and over what time period; which makes people feel and function better. These questions and others need to be asked about many of the things we do, and comparative effectiveness research is a reasonable way to approach this.
To ignore these questions because we don't like the answers is so frighteningly ignorant that it's hard to believe an intelligent person could suggest it. Knowing these answers doesn't mean it's time to start making Soylent Green. What we do with the information is where our ethics as individual and as a society are tested. If we find that kidney dialysis in eighty year olds on average does not provide much quality or quantity of life, do we decide to stop covering it? Do we create algorithms for deciding what do offer an individual? Do we make a subjective choice in each case?
(Photo credit: taekwonweirdo on Flickr.)
