The Need for Health Reform

Lest anyone misinterpret my previous blogs, I believe that our system is desperately in need of reform.  As I read President Obama’s opinion piece in the Sunday New York Times this weekend, I strongly agreed with some of the arguments he put forth to support health reform.  He highlighted a number of issues that are important to address in any health reform package and HR 3200 does effectively address those. 

Pre-existing Conditions Clauses

In that article, President Obama wrote “A 2007 national survey actually shows that insurance companies discriminated against more than 12 million Americans in the previous three years because they had a pre-existing illness or condition. The companies either refused to cover the person, refused to cover a specific illness or condition or charged a higher premium.”  While I would argue with the word “discriminate” as companies that do not discriminate and cover those with pre-existing conditions would have to charge higher premiums and would not be able to continue in business, the ability to exclude someone because of a pre-existing condition has been problematic for years.  If you speak to health insurance executives, they will tell you that they maintain those clauses in order to keep premiums low for select groups.  If you eliminate pre-existing conditions clauses, rates for many policies, especially individual and small group policies will go up.  Despite that I still believe that these clauses should be outlawed as they go against the basic premise of shared financial risk that is inherent in good insurance.  HR 3200, in Title I, Subtitle B, Section 111 does prohibit pre-existing condition exclusions and I see that as very positive. 

Policy Maximums

In that same article, President Obama states “They will no longer be able to place some arbitrary cap on the amount of coverage you can receive in a given year or in a lifetime. And we will place a limit on how much you can be charged for out-of-pocket expenses. No one in America should go broke because they get sick.”  What he is referring to in this quote is the yearly and lifetime maximums that some policies have in place.  A policy may now state that over the entire lifetime of the policy, it will only pay to a maximum of 1 million or 2 million or 5 million dollars and after that the benefits stop.  Obviously, if you have a severely catastrophic illness and go over that cap, you have no recourse other than some sort of public program.  Here again, eliminating these maximums will increase premiums for everyone, especially those who have individual policies and policies through small businesses.  However I am in agreement that this is needed to prevent people from compounding their illness with severe financial distress.  Section 122 of the same section of the bill that I cite above states that insurance coverage “does not impose any annual or lifetime limit on the coverage of covered health care items and services”  I see that as a plus and a needed change in law. 

Pass Those Clauses Now

There is really no reason that our legislators cannot pass these two sections now as a separate law.  There is no rule that makes all of the pieces of this legislation fit together.  We can find agreement for individual parts of the bill and I only hope that we can find the political will to make those changes that are needed.

Comparative Effectiveness and Health Reform

The house health reform bill makes interesting reading once one gets past the arguments and into the details. One interesting section is Title IV - Quality, Subtitle A - Comparative Effectiveness Research, Section 1401, Part D. This section takes a mere 1 billion dollars (a very small part of the 1 trillion dollar total) to set up an infrastructure to fund and develop comparative effectiveness research. In the words of the bill, "a Center for Comparative Effectiveness Research to conduct, support, and synthesize research with respect to the outcomes, effectiveness and appropriateness of health care services and procedures in order to identify the manner in which diseases, disorders, and other health conditions can most effectively and appropriately be prevented, diagnosed, treated, and managed clinically" will be established. It goes on to form a "Comparative Effectiveness Research Commission to oversee and evaluate the activities carried out by the Center to ensure such activities result in highly credible research and information resulting from such research". In other words, it sets up an oversight Board and a bureaucracy to develop, monitor and prioritize this type of research.

Comparative Effectiveness Research Today

One of the pioneers of effectiveness research for the past twenty plus years has been Dr. Robert Brook who has done his work at the Rand Corporation. In an article in July in the Journal of the American Medical Association, Dr. Brook clearly and concisely described what comparative effectiveness research really is. He gives a simple example to illustrate the research. "Consider, for instance, a company manufactures an improved surgical needle. Comparing that needle to the needle currently used could be included in comparative effectiveness research. A nearly infinite number of studies could be conducted to determine how often a person with back pain should receive chiropractic treatment, how often a person with hypertension should receive follow-up care, how often a patient should obtain a dental checkup, or what form of radiation and chemotherapy will achieve the best outcome for a patient with cancer."

In the article he goes on to describe guiding principles that should be used to ensure that the government funded comparative research does not turn into a "free-for-all or a full employment program for health services researchers and epidemiologists".

The Real Need for Comparative Effectiveness Research

I agree completely with Dr. Brook's approach and I encourage all to read it. I do, however have a different thought. How about comparative effectiveness research for legislation. Rather than just pass a health care bill, let's spend 1 billion dollars setting up a Comparative Effectiveness Research Center and Commission to fund studies on the comparative effectiveness of different bills and different government programs. I for one would love to know if paying for end of life counseling, as called for in HR 3200 actually results in people dying with more dignity and with more support from family. How about expanding it and assessing the comparative effectiveness of specific congressmen and senators? I really think we may be on to something with a bill like that.

Comparative effectiveness is a concept whose time has come. Let's just not limit it to medicine. I believe it is in assessing the outcomes of the work of our governing bodies where it is most sorely needed.

The Health Care Reform Debate

The debate over health reform has degenerated badly and has become less about improving the health delivery and health insurance systems and more about which party can "win" and paint their opponents as evil or misguided in order to win future elections. We really have to change the tone of the debate and focus on the two problems that we are trying to solve. They are the problem of access to health care, especially for the 47 million Americans who currently have no health insurance, and the problem of high costs in health care. These are separate problems that will, in all probability need separate but coordinated solutions.

Access to Care

The number of 47 million uninsured is both true and misleading at the same time. If one looks more closely at those who are uninsured, they can be subdivided into certain subgroups. In the US census data from 2006, it was found that over 9 million of those uninsured have incomes over $75,000 per year. Another 8.2 million have incomes over $50,000. Many of the uninsured are young and while they can afford the coverage, don't see the need. We probabaly have about 18 million Americans who are truly uninsured and often uninsurable. Any number of people with no access to care is too many. As I read it, the current House bill is more directed towards solving this problem than towards solving the problem of high costs.

Lowering Costs

Total health care cost is a function of the unit cost of the services and the volume of services rendered in addition to our administrative costs and our amenity costs. While those administrative and amenity costs (which includes costs such as private rooms in hospitals) increase total costs they are not major contributors to our health care inflation. In order to lower costs, you have to lower the unit price of the services, which would mean lowering doctor's incomes, lowering hospital revenues, and lowering payment for new equipment, new drugs and other services or lower the volume of services that are rendered. In the United States, high tech and invasive services, such as MRI exams, surgeries, endoscpies and the use of new drugs have very high volumes and also exhibit the most "waste" as they often are used but often do not change the patient's outcome. Numerous studies have shown that these services and products are not useful about 30% of the time they are used. The volume of these services in the US exceeds other countries by 40 - 50% or more. In order to lower costs, we would need to lower these volumes signficantly. The challenge there is that while 30% of that volume is clearly unecessary, when programs are put in place to eliminate the unecessary care, needed care often also gets eliminated.

Putting the Two Problems Together

In many ways, the health reform debate is about the difficulties of adding millions of people to the health insurance system while also lowering the volume of services in total that are delivered to the population and still maintaining all needed care. This is an extremely difficult problem which inevitably forces decisions to be made about what care should be paid for and which care should not be paid for. The legislative instrument in making these decisions is rather blunt and that is a major part of our current dilemma.

There are ways to address the cost problem. One way is to remove the fee for service system that we have and move towards other payment systems that pay salaries for physicians or pay them in more "bundled" ways for the care of an illness. Under a bundled payment system, a physician or a health system may be paid for the complete evaluation and treatment of an illness (heart disease for example) and that payment would include everything from doctor's fees, to hospital costs to medications. Right now the evaluation and treatment of that heart disease includes sepaarate payments to multiple doctors in multiple specialities. All of those people, products and services would still have to be paid for in a more bundled system however such a payment system would create incentives to keep the costs of evaluation and treatment lower. However, make no mistake about it; the American public prefers incentives to do more over incentives to do less. We tend to prefer knowing that everything possible is being done when illness strikes. Finding a solution to lowering costs is thus a cultural challenge as much as an economic or political one.

How the Current House Reform Package Attempts to Solve the Problem of High Cost

To put it succinctly, it doesn't. It does address the issue of access by bringing many people into the health insurance system however the approach to lowering cost is mainly achieved by putting into place (for the long term) more electornic interfaces in medical record keeping and medical care, and also putting into place more government involvement in payment, benefits, and the development and maintainenece of medical care standards. Currently, the government does set fees, benefits and payment systems for Medicare and Medicaid. Most physicians and hospitals believe that the Medicare fees are very low and that the Medicaid fees may not even be enough to cover overhead expenses.

The example of End of Life Care

The loud debate over the end of life care provision in HR 3200 is a very good example of all that is wrong with the tenor of the debate and some of what is problematic in the bill itself. The goal of increasing people's options for themselves and their families at the end of life is a laudable one. As a physician, I have seen people have nothing but pain in their final days and weeks of life because they have not been given all of the options as to how they want to spend those finals days. Does the health care reform bill encourage a positive and loving way to approach one's final hours or does it result in government death squads? The reality is that it does neither. One really does need to look at the exact language in the bill to determine what is really being proposed.
Section 1233 entitled Advance Care Planning Consultation describes in excrutiating legal language all that must be done in order for a physician to charge for end of life counseling. It does not mandate the service but it does regulate it very specficially even describing the quality control for that service. This specificity can actually cause more fragmentation, at least in the billing process. A good physician does these services as a matter of course and can bill for it under the current billing system. It is an office visit. The troubling aspect of the provision is the attempt to push the physician into a script rather than encourage him or her to listen to their patient in order to understand their needs and counsel them in a customized personal manner. When government mandates specific language and approaches, costs can actually increase and the personal nature of medical care can suffer. So while I believe that end of life counseling is an important part of practice, I also believe that including it in the health reform bill will not further the goal of getting more counseling preformed in a personalized way. It will only increase administrative costs and fragment billing which also leads to higher costs. It may also further a troubling trend towards a depersonalization of medicine, at the time of life when the most personal type of service is needed.

So What Do We Do?

I hope that what we do is start to speak openly about the options and not just talk about being for or against health reform. We are all for improving the access to health care and making it more affodable and at the same time we are all for maintaining and improving the quality of care that all receive. The only question is what exact provisions need to be in the bill to best encourage those goals. There is honest disagreement about those provisions and I can only hope that the debate takes the time and care to evaluate each provision so that we end up achieving the best possible solution.

The Patient's Story

Medicine and health care have never really been about the science. They have always used science but the real essence of medicine has always been in each person's story. An illness is never just an illness but it occurs within a person's entire life. The social, financial, spiritual, emotional and intellectual aspects of each person affects the illness and the illness affects all of these factors as well. More and more medical journals have understood this and more have been publishing first person accounts of these "stories" often written by doctors and occasionally by their patients, in order to give voice to the individual's unique story. The granddaddy of them all is the Narrative Matters section in Health Affairs which is perhaps the most prominent and widely read of the health policy journals. In honor of the tenth anniversary of Narrative Matters, Health Affairs in the latest issue has four narratives by wonderful authors including Abraham Verghese, Julia Alvarez, Alexander McCall Smith and Fitzhugh Mullen who was the original editor of Narrative Matters. As Ellen Ficklen, the current editor writes in her introduction to these four stories, "The peer-reviewed personal essays link a health care–related story or anecdote to the bigger picture. In doing so, underlying all of the undeniably important statistics and data involved in policy, they demonstrate the basic truth that health policy has human consequences." Not only does health policy have human consequences but medical care is always best when it understands the human being behind the disease. A strong narrative communicates this better than any medical text. Unfortunately, in todays world we have often left these narratives behind in the care for the patient. In a world in which we have ten minutes to see a patient and half of that time is spent looking at a computer instead of listening, finding a true unique person behind the symptom becomes next to impossible. I can only hope that the trend to communicate the story is part of a larger trend to bring true care and understanding back into healthcare.

Sham Surgery

Studies in which patients undergo phony surgeries are always interesting to me. The moral dilemma of asking a person to take part in a study in which they are taken to an operating room, perhaps put to sleep or at least drugged to some extent and then "invaded" by a knife, a needle, a scope or some other medical instrument is, in and of itself troubling and yet fascinating. At the same time it is impossible to deny the valuable facts that can be found with such studies. In this week's New England Journal of Medicine, two such studies are published involving a procedure called Vertebroplasty which is a treatment for spinal fractures caused by osteoporosis. The procedure was found to have absolutely no value to patients. It is scary to think about how many other surgeries and procedures are done every day that may have no value and yet puts people at risk. At the same time it is also scary to think about doing more sham studies, putting people at some risk of sedation, site infection, and other risks both major and minor to further this type of knowledge. I hope that we always consider the moral dimension for individuals as we preform these types of studies and also hope that we can eliminate surgeries and procedures that do not add value to a person's care.

Obligation and Choice

Let's say you have a really bad disease, like cancer for example. A doctor comes along and asks if you will take part in a study but in order to do so, you will need to take medication but not know if it is real medication or a placebo that will not do anything. These types of studies are the heart of "double blind studies" that are core to clinical research. In other words you are being asked to be a guinea pig for the betterment of mankind and medical science. Do you have an obligation to say yes? According to the authors of an article in JAMA in July, you do! Schaefer, Emanuel and Wertheimer argue that for a number of reasons, the decision to participate in biomedical research as a patient is a moral obligation and not merely a personal choice.

While they are careful to make a distinction that it should not be a legal obligation, they say that if you answer "no" to my initial question and do not take part in the study, you are morally wrong. You are a bad person. I am troubled by that position. The standard approach to such questions is that an individual has the right to decide these issues for themselves and that the morality of the decision is not an issue and no judgment as to the morality of the individual making the decision is passed.

Perhaps I worry too much about the moral assuasion becoming a legal one but I want to keep my autonomy and not be pressured into taking part in studies that I feel are not valid, not helpful and not in my or societies best interests. I do not want to have a system in which people are shamed into taking part in studies that are designed more for the scientist doing the study and less for the patient. Let me make that decision on a study by study basis without the societal pressure that this article seems to endorse.

How do you feel about this? Let me know.

Restarting

It has been a long time since I picked up the "pen" to write my blog. For any number of reasons, I have suffered from blogger's block (if such a thing exists). This month, an article in JAMA troubled me enough that I feel compelled to restart my musings, focused mainly on the sometimes brilliant and sometimes not-so-brilliant material that is published every day in the medical literature. I will post a separate note about that article.

In restarting, I feel the need to explain. My writings are mainly focused on new articles that are printed in the peer reviewed medical literature. The peer reviewed medical literature for those who are less familiar with the way medical progress moves forward, is the chief mechanism for new health knowledge to be distributed, challenged and ultimately accepted. A new fact is not considered a fact until it has undergone significant vetting through this literature, a neverending process to some extenet. I admit to a love of this genre despite it often being obtuse and difficult. My main goal in this blog is to take that sometimes incoherent body of writing and make it understandable to the general public. Think of me in this regard as a cross between a critic and an interpretor.

So I restart, renew and reinvigorate my blog. Here's hoping it creates clarity rather than more confusion.