Friday, July 31, 2009

Swift-boating the healthcare reform in the month of August*

Do you know the kids' book "Officer Buckle and Gloria" by Peggy Rathmann? It is a story of a police officer and his dog Gloria, who, as a team, go around the local schools giving such useful safety tips as "do not stand on a swivel chair". They are a big hit: they teach and make kids laugh, and their popularity soars to the point where a news team films one of their presentations. Watching it that evening on TV, officer Buckle has an epiphany about the etiology of their popularity: it is Gloria's charming antics, acting out his tips while standing behind him on the stage! Naturally, officer Buckle feels like a fool and slips into a depression and refuses further engagements, but it's OK, because Gloria is the real attraction, and she is still invited to talk, and she fails miserably without her buddy to the point that both she and her audience are depicted in the auditorium in a peaceful slumber. Z-z-z-z-z...

This is how I am beginning to feel about this whole healthcare "debate": z-z-z-z-z. The public is bogged down with worsening economy, the press are colluding with the Republicans in spreading mis-information, a la the Swift Boat gate. Members of Congress are day-dreaming about their summer recess, and the President is busy chugging Bud light at a teachable summit. So, among these doldrums, in walks Paul Krugman with his Nobel Prize in economics, and in a few computer strokes says as much as Tolstoy could say in a novel, and just as eloquently: Get your facts straight, you anti-government conspiracy-theory bile-spewing idiots! You owe whatever small amount of success exists in our current healthcare debacle to government regulation. Between Medicare and Medicaid, caring for the elderly and the indigent, respectively, and tax incentives for employers to cover their employees, while taking away their ability to cherry pick the healthy ones and rescind those with "pre-existing conditions", the government is already responsible for the parts that work.

This over-$2-trillion behemoth, and many of those feeding at its trough and promoting inefficiency, inequity and overuse, needs to be reined in! With the economy in the slump, and the US index of production, the GDP, continuing its nose-dive, our healthcare spending is continuing to increase, and I would not be surprised if it came in around 25-30% of the total GDP by the end of 2009. This would be a good investment, if the health of the population was improving. But with the rates of obesity on the rise, the threat of a tough flu season ahead that we are ill-prepared for, and fully 40% of the population carrying a chronic disease diagnosis, this does not appear likely.

So, let me reiterate a few points. If you worry about reduced incentives for innovation, don't: manufacturers' own risk-averse attitudes in response to market pressures have already squelched innovation. If you worry about the government getting into your affairs, don't: the role of the government will be well defined and limited to providing the funding and the tools necessary to make rational care decisions. If you worry about rationing, don't: we have a long way to go in cutting away the fat of unnecessary care before we get to the lean mass of what is useful and effective. And please, do not confuse "rational" with "rationing". Rational is what you will get if comparative effectiveness research is allowed to do its job. Rationing is what you are getting now from the suits in the boardroom who refuse to pay for your care.

So, as any doldrums, these too will pass. In the "Officer Buckle and Gloria", as you can imagine, officer Buckle sees the light and understands that he and Gloria are a team, and without him the schtick does not work. So, in the all's-well-that-ends-well fashion of children's books, the two friends get back together to the delight of their fans. Will our reality end well? I do not know, but what I do know is that without our involvement this healthcare schtick will not work. So, during the August recess we need to resist the slumber of summer and continue to pressure our elected officials to do the right thing: bring us quality equitable healthcare that will not bankrupt our children's future.

*I cannot take credit for this "Swift-boating" terminology, which I have respectfully borrowed from the Chairman of the DCCC, Chris Van Hollen

Thursday, July 30, 2009

Here we go again

Well, if the Wall Street Journal thinks it's OK to recycle their material, why not Healthcare, etc.? Or wait, I cannot tell, is today's rant by Betsy same as or different from the one 4 days ago? Well, no matter, the sentiment from my previous post below is worth repeating.

For someone who spent her childhood behind the iron curtain, George Orwell's novels were at once prophetic and horrifying. Reading about "spontaneous demonstrations" in Animal Farmevoked images of my own participation in the May day parades, designed less to show solidarity with workers of other nations than to show off the contrived unity and the military might of the former USSR. To me, the double-speak captured by Orwell was chilling.

With an equally chilling Orwellian turn of phrase, in her op-ed piece in today's Wall Street Journal, Betsy McCaughey contributed fuel to the conservative hysteria over the proposed healthcare reforms. Her comments were beautifully deconstructed by SHADOWFAX on his excellent blog Movin' Meat. Ms. McCaughey currently serves as the chairperson of theCommittee to Reduce Infection Death, whose homepage incidentally sports a familiarly eerie Bushism "Save lives just by searching & shopping". She fanned the flames of status quo by asserting that the legislation as written will ration healthcare delivery to our seniors practically to the point of advocating convenience euthanasia, an abhorrent practice by some veterinarians for their clients whose dogs may have inconvenienced them by peeing on their favorite rug. With a single swing of her literary sledgehammer she tried to crush AARP'ssupport for the much needed reform.

No argument against the reform rang more hollow than her disapproval of funding for comparative effectiveness research (CER) in the recent stimulus package, intended to demystify the value propositions of healthcare interventions. The allocation of $1.1 billion to CER is long overdue, as we have been unable to say "no" to reimbursing anything from a me-three anti-hypertensive to an MRI for low back pain to a bypass operation for a 95-year-old with limited quality of life. Equating this initiative to rationing is true double-speak that can succeed in creating panic only under the assumption that we are, well, stupid.

If Medicare is to survive long enough for my peers to benefit from it, it needs to undergo severe liposuction, with CER as the rational framework. Let's stop wasting time, breath and trees on these unimaginative doomsday scenarios and move on with the work of fixing this broken system. Still, if this Napoleon-like discourse is the lynchpin of the conservative strategy, don't let me stop them from discrediting themselves.

Wednesday, July 29, 2009

Voodoo Medicine

An excellent post the other day on the Science-Based Medicine blog addressed "Incorporating Placebos into Mainstream Medicine". In it the author, Harriet Hall, rails against complementary and alternative medicine as inherently leveraging the placebo effect. She goes on to ask "What if scientific medicine were to co-opt the CAM movement? We could take these treatments out of the hands of the less ethical practitioners and outright scam artists and place it in the hands of those who are more likely to be altruistic". This mouthful grabbed my attention.

Here is what bothered me. The traditional healthcare providers believe that they are practicing scientific medicine. And why wouldn't they? The clinical research establishment (of which I am a part, mind you) is constantly touting new breakthrough results, and the FDA after all only approves therapies that are proven to be effective! Well, not so fast; there are an awful lot of assumptions in this statement. First, how much of the research out there is of high quality and how much is bovine excrement? Next, even the best of studies that find statistical advantages to one course of action over another show minute, potentially inconsequential differences that a lot of the time translate into zero benefit outside the laboratory of clinical trials. And as for the FDA, they are paid by the manufacturers to review and approve drugs and devices. And even though I trust in their earnestness, most of the time they require only statistically significant differences (microscopic ones can still emerge given a large enough study size) in outcomes that are not all that meaningful to one's well-being (e.g., drop in cholesterol as a surrogate for a reduced risk of death from cardiovascular disease, a less straight-forward relationship than you might suspect).

So, there is the science bit. As for ethics, I will give Dr. Hall that for the most part MDs do try to practice what is commonly accepted as scientific medicine. The key here is "for the most part". Remember Gawande's story of McAllen, TX? And lo' and behold, just a few hours ago Reuters reported a bust of a large Medicare fraud scheme, where, believe it or not, docs were charging $3,000 to $4,000 for simple knee and shoulder braces and heating pads, calling them "arthritis kits". And while I do not question the ethics of the majority of my brethren, this incident sure underscores that, just as CAM practitioners, the house we live in is also made out of glass.

We have a long way to go to achieve good health in this country. Our culture has become over-reliant on experts in everything, including healthcare and evidence, to slap our wrists when we have been "bad" and to give us marginally useful advice on how to cure our ills. We must question our assumptions. I agree with Dr. Hall, nothing replaces a combination of evidence and experience. Or the placebo effect.

Anatomy of peer review

Just did a survey from "Sense About Science" on the relevance and adequacy of peer review in academic research. It gave me the chance to vent some of my frustrations with the process as it stands -- incompetent reviewers, editors wasting my time as a reviewer on unmitigated trash that they should have rejected out of hand, acceptance/rejection decisions that clearly ignore the reviewers' recommendations, and the biggest one of all: time from submission to acceptance and ultimately to publication. The last gripe is of particular importance in the face of today's electronic world and the fast pace of issues evolution: what is relevant today may either be irrelevant or too-little-too-late tomorrow.

But let's step back and define peer review process, its purpose and how well it accomplishes it. What is peer review? Well, it is just that: a review of the write-up of your research by a group (usually 2-3, but I have had as many as 7) of your peers. Here is how it usually works, for those who have not partaken of the publication process. You submit a paper to the editor of the journal of your choice asking to consider your work for publication. The editor in most cases will take a quick look at the paper and decide whether it even merits review or whether it is a complete waste of time. I have to say that, as a reviewer, I appreciate this part of the process and view its absence as disregard for my time. Once the editor has decided that the paper is worthy of further critical review, he/she, sometimes with the help of the authors, identifies the appropriate reviewers and solicits them to undertake the review with a 2-week turnaround. If the reviewers accept, all is well, and if not, other reviewers need to be solicited.

Now, "peer" in research is only a little less difficult to define than in the judicial system. Is it anyone with an advanced degree comparable to yours? Is it well-known scientists in the field that you write about? Is it the select group of people who are intimately familiar with the narrow questions that you focus on? Go too broad, and the reviewers have no context for your work, and context is so important to understanding whether you are presenting something of value or just composting old rubbish. Go too narrow, and you get into the "everybody-knows-everybody" situation, where turf and personality wars may win over substance.

Well, OK, so now there are reviewers willing to cast a critical eye upon your work, now what? If you are lucky, you get an e-mail from the editor in 8 to 10 weeks with 1). outright rejection, or 2). immediate acceptance with no or minor revisions, or 3). extensive comments from the reviewers, each of which has to get addressed, line by tedious line in both the manuscript and a separate document aimed at soothing their concerns. Now, don't take me wrong, many a paper of mine has benefited from careful and cogent reviews from very smart people. On the other hand, I have also spent countless hours trying to be complete and respectful in my responses to utter idiocy.

So now, after spending days to weeks responding and revising, you are ready to resubmit. And here is another place where some journals are great, where the editor takes the time to look at the responses and makes a quick decision to accept or reject. Others will send the responses and revisions back to the reviewers and you have to wait another 6-8 weeks for them to get back to you. If you are lucky, all reviewers are now happy and have recommended acceptance; if not, you have to draft the second round of responses and revisions and the wait begins all over. My favorite is when in the third round of reviews from 7 reviewers, all but one are happy, and the last one has found a missing comma, which you have diligently corrected, and the journal returns your responses and revisions to the reviewer for their approval... Absurd, but has happened to me.

Finally, you have satisfied everyone and your paper has been accepted for publication. The trend nowadays is for journals to have a rapid online publication shortly (within days to weeks) after acceptance. However, with some journals, even their e-publication takes another 3-4 months. Argh! So, now it has been 10 months since you first submitted your paper to the time it sees the light of day. And the results are embargoed until publication, so you cannot share with your peers, the public, the press, or even your mother at the risk of being spanked (well, OK, just withdrawn from publication). Is this really the best we can do in the 21st century?

All of my ranting notwithstanding, peer review is necessary, as major decisions about our health are made based on this research. The question is how can it be improved within the context of our current needs and capabilities. What would it be like if we moved away from chunking science into packaged and self-contained bits we think of as manuscripts and started to think of this work as constantly evolving? Here is what I mean: I put a paper with my recent data on a web site where anyone can come and look at it and critique it, provided they are willing to disclose their identity and credentials. I get to see their comments in real time and respond to those that seem legitimate to me (or to the site's editorial board) and revamp my paper accordingly. Yes, things become a bit of a moving target, but this type of process incorporates the dynamic nature of the evolution of scientific thought. It would for sure take us out of our comfort zone, but it may also prevent traditional journals from getting irrelevant.

Or perhaps, in Twitter fashion, we should hold all our scientific communication to 140 characters or fewer?

Tuesday, July 28, 2009

Imagination and H1N1 preparedness

Got an e-mail today from a Bloomberg reporter asking about my thoughts on the state of US preparedness for H1N1. Specifically he was interested in the ICU capacity as it applies to dealing with the more severe respiratory failure that has been reported in association with this infection. You might wonder why he called me of all people. Well, this is because I published a bunch of papers recently (that have been dutifully ignored by policy makers) that quantify the expected stress to the healthcare system in the US posed by the sky-rocketing increase in the population of patients requiring ventilators to assist them with breathing. How naïve I was to think that our numbers might be used for planning purposes, so that we could be better prepared for this growth!

A year since we first started to come out with the numbers, there are still no reliable estimates, or even attempts to derive them, as far as I can tell, of the US ICU surge capacity. And this information is more critical now than ever, as we are faced with the potential for untold numbers of H1N1-related hospitalizations accompanied by severe respiratory failure. It is shocking to me that we are leaving these infrastructure issues to chance.

But wait, why am I so shocked? This is just another byproduct of our fragmented healthcare "system". There is no one either to take or to designate responsibility for planning. While our professional organizations are doing the best they can, their approach is usually siloed and somewhat distracted: in case you have not heard, we are also tackling the most rampant pandemic of antibiotic resistant infections, which affects ICUs disproportionately.

So, who will take charge of this hot potato? The CDC? Homeland Security? FEMA (chuckle-chuckle)? Press your representatives to tackle this thorny issue, because if you are worried about planned rationing now, wait until you see what unplanned bedlam looks like. Condi Rice said that the US intelligence community just did not have the imagination necessary to anticipate the 9/11 terrorist attack. Let us not have to resurrect this tired excuse this flu season.

Monday, July 27, 2009

A convenient failure

In his latest blog post Robert Reich makes the case for enacting at least the House healthcare bill prior to the August recess, lest our attention-deficient legislators lose their focus over the break, or worse yet have the opportunity to hide behind even more egregious lies about how universal healthcare will infringe on our civil liberties. But the bill will be a self-fulfilling prophecy if it does not contain real provisions to rein in costs.

Here is what I mean. From the beginning I was suspicious about the motivation behind AMA's support for the bill as proposed, and, of course, there turned out to be some favorable language on the Sustainable Growth Rate (SGR) that promised physicians much smaller cuts in reimbursements than previously feared. And although I do not begrudge the overworked and underpaid docs a stable income, there has to be some adjustment for the abuse and overuse. Furthermore, yes, I was encouraged by the inclusive discussions between the White House and the industry stake holders -- Pharma, hospitals, insurance providers. And though it was heartening to see them sing Kumbaya and drink wheat grass juice with the staffers, my feeling has always been that cost-containment has to be regulated, so that our collective amnesia does not prevail and forgive inaction.

So, what will happen if the bills that come out of Congress make a mockery of cost-containment? Well, I think it will be a very nice political smoke-screen for the opponents of universal healthcare. Here is how it will play out. First, there will be some rhetorical wrestling about whether it is OK to tax the ultra-rich to pay for the reform. Then, although the conservative elements will make some noise about how it is un-American to redistribute the wealth this way, they will quickly acquiesce. This way they can cover themselves on both sides of the fence: by briefly disagreeing they will have shown those who fill their coffers that they are willing to stand up for their interests, and then by letting go they will be supporting the course popular among 99% of their constituents suffering through the recession.

Thus, my guess is that a toothless bill will pass that will start covering a few of those who do not now have access to care... and will soon run out of revenue only to appear as a gigantic Democratic failure, playing conveniently into the hands of those in whose interest it is to maintain the status quo. This will be a painful "I told you so" for the American public, the majority of whom desires universal coverage. In my opinion this is a dangerous game played by a devastated political party to gain a political advantage. This game is played at the expense of our health and welfare, and we would be foolish to allow ourselves to be manipulated by this double-speak.

Back in the 1950s Harry Truman' attempt at reform failed because of the nation's willingness to believe the message of demagoguery delivered by a second-rate actor. This is the 21st century; we have a devastated economy, a healthcare system in ruins and an opportunity to provide what all other responsible nations provide: access to an equitable quality care. We must make sure that the Beltway follies do not ruin this chance for all of us.

Saturday, July 25, 2009

How the healthcare debate is changing the face of religion in the US

"Jesus was a community organizer" proclaimed the bumper sticker on the beat-up Volkswagen in front of me, right next to another informing me that "This car is powered by vegetable oil". This got me thinking: "He sure was". If we are to believe the story of Jesus, his approach to change was grass-roots bottom-up subversive. In fact, he was the original social networker -- by building a small group of committed and credible individuals around him he amplified his teachings through their mouths, thus reaching thousands of people. His discourse often included a lively debate with room for disagreement and not much dogma. In fact, Jesus would have been for universal healthcare!

And I am no longer one of the few realizing this: today's Washington Post has confirmed my suspicions. The story is about multi-denominational religious coalitions organizing to support healthcare reform. Once a hot potato in the faith community, healthcare in the US is in such disrepair that not to speak out on behalf of change would be hypocritical. And so, thousands of faithful have been meeting with their Members of Congress and holding rallies in support of healthcare reform. This effort bears the community organizing signature of President Obama via his faithful, charismatic and brilliant disciple Joshua DuBois, executive director of the White House Office of Faith-Based and Neighborhood Partnerships. Josh has brought together this strong, vocal and diverse coalition to stand up for the indisputable value of inclusion.

Of course, no good deed goes unpunished, and, of course, conservative Christian groups accuse them of using "the common language of faith to disguise unpopular ideas". Hmm, so providing all people access to quality healthcare is not a popular religious platform? Next they will tell us that they support capital punishment. Oh, wait, they do... This reactionary stance smacks an awful lot of the pre-Obama era White House Office of Faith-Based Initiatives, created by Bush to divide and conquer rather than to unite and assist. I am glad to know that these anachronistic voices are just remnants of our eight years of infamy, drifting inexorably into our historical past. Let's hope that the rest of us can continue to move forward as a nation united behind the humanistic idea of universal coverage.

And this brings me back to the bumper sticker. While sitting in traffic and staring at it, another thought occurred to me: "Well he sure wasn't a cowboy." He sure wasn't (no offense to any cowboys with the good sense to be reading this post, of course).

Friday, July 24, 2009

Pleasure centers and the media

We, the US public, are much like that laboratory rat with an electrode in its head, pressing the lever ad nauseam in search of pleasurable stimuli. Except in our case the lever is in the voting booth. That, I believe, is the root of many of our current woes, healthcare and economy included. Here is what I mean.

On tonight's Marketplace, NPR's business program, host Kai Ryssdal interviewed Megan McArdle of the Atlantic Business Channel and Leigh Galagher of Fortune Magazine about the week's developments in the healthcare debate. One of the ideas discussed was that real healthcare reform is likely to bring immediate pain, and any benefits are to be expected in the longer term. And, of course, by then the legislators who ushered in this change would be voted out of the office by their irate constituents as punishment for the short-term sacrifices.

This attention to the short-term is a direct result of our over-exposed and over-analyzed culture of politics. In the sound bite reality of instant communication perception is reality. This makes the politicians not just circumspect, but utterly deliberate in how they appear to the public. They know that every statement, if not examined from every conceivable angle and honed through exhaustive polling, can serve as their undoing if perceived as a mis-step (think the furor over the Obama statement about the Gates arrest). A politician, even the rare earnest one, does not get a second chance to explain himself or his or her complex views not amenable to sound biting.

This media folly applies not only to the healthcare debate, where rampant self-interest masquerades as a perception of fiscal responsibility, but also in the economy as a whole: the instant trading with its attention deficit to long-term growth has partly contributed to our current economic situation, if not directly, then through demanding exorbitant short-term returns at the expense of long-term value.

Now, I am not a luddite -- I enjoy technology and its benefits. However, technology needs to be used responsibly. Thoughtful reporting shapes public opinion. This power should be used in the name of building a better more equitable society rather than for building profits through sensationalized attention grabbers. As the US public we should demand this. Otherwise, all we are doing is enabling the pressing of the electrode in the rat's head.

Peter Orszag's political incorrectness

This morning's Wall Street Journal features an article by Laura Meckler entitled "Obama's Health Expert Gets Political". In it Ms. Meckler describes Orszag's foray into the heated Congressional debates about reigning in healthcare costs. Among other measures proposed by Orszag is the expansion of powers of the Medicare Payment Advisory Committee (MedPAC). In its current role MedPAC makes recommendations to the Congress, who can follow or ignore them. One example is the recommended $200 billion in cuts in the last year promptly ignored by our legislators.

Of course Members of Congress as well as such powerful regulators as the Department of Health and Human Services are opposed to the increase in MedPAC's powers. Why? Because for them power is a zero-sum game: MedPAC's increase will result in their decrement. But what does it mean for the consumer? Why should we trust Congress to promote efficiency? In fact I would argue that they see their jobs as maintaining the status quo -- would special interest groups be spending $40 million over 3 months or $1.4 million per day on lobbying efforts if these did not influence the legislators? For Congress, their political interests will always outweigh ours. And what about the DHHS? Well, if you consider that its components are such agencies as the FDA, who gets major funding from the manufacturers to review their products... Well, you get the picture, right? The status quo is working for them.

In comes the idea of a MedPAC with teeth: they make the recommendations and they have the power to carry them out. Of course all the special interests are trembling in their boots! Of course there is a swell of Orwellian rhetoric inciting panic among the uninitiated that the government will kill our grandmothers in the name of money! Come on, this is all disingenuous lies thrown at the public in hopes that we are idiots!

Orszag's stance is not politically popular because there are some hard things that have to happen. We as investors and as consumers will need to tighten our belts to make this reform successful. The irony is that, whether or not the reform passes, the belts are getting tighter. How will we feel if this tightening, instead of providing efficient and accessible care for our fellow citizens, simply continues to subsidize the annual bonus of the $12-million insurance company CEO?

Thursday, July 23, 2009

George Orwell and healthcare reform

For someone who spent her childhood behind the iron curtain, George Orwell's novels were at once prophetic and horrifying. Reading about "spontaneous demonstrations" in Animal Farm evoked images of my own participation in the May day parades, designed less to show solidarity with workers of other nations than to show off the contrived unity and the military might of the former USSR. To me, the double-speak captured by Orwell was chilling.

With an equally chilling Orwellian turn of phrase, in her op-ed piece in today's Wall Street Journal, Betsy McCaughey contributed fuel to the conservative hysteria over the proposed healthcare reforms. Her comments were beautifully deconstructed by SHADOWFAX on his excellent blog Movin' Meat. Ms. McCaughey currently serves as the chairperson of the Committee to Reduce Infection Death, whose homepage incidentally sports a familiarly eerie Bushism "Save lives just by searching & shopping". She fanned the flames of status quo by asserting that the legislation as written will ration healthcare delivery to our seniors practically to the point of advocating convenience euthanasia, an abhorrent practice by some veterinarians for their clients whose dogs may have inconvenienced them by peeing on their favorite rug. With a single swing of her literary sledgehammer she tried to crush AARP's support for the much needed reform.

No argument against the reform rang more hollow than her disapproval of funding for comparative effectiveness research (CER) in the recent stimulus package, intended to demystify the value propositions of healthcare interventions. The allocation of $1.1 billion to CER is long overdue, as we have been unable to say "no" to reimbursing anything from a me-three anti-hypertensive to an MRI for low back pain to a bypass operation for a 95-year-old with limited quality of life. Equating this initiative to rationing is true double-speak that can succeed in creating panic only under the assumption that we are, well, stupid.

If Medicare is to survive long enough for my peers to benefit from it, it needs to undergo severe liposuction, with CER as the rational framework. Let's stop wasting time, breath and trees on these unimaginative doomsday scenarios and move on with the work of fixing this broken system. Still, if this Napoleon-like discourse is the lynchpin of the conservative strategy, don't let me stop them from discrediting themselves.

Wednesday, July 22, 2009

Cadillac or Prius healthcare?

Reuters' Maggie Fox has filed a report today called "No 'Cadillacs' in US healthcare reform proposals". She gives an example of a BCBS plan that is considered by most a "Cadillac" of healthcare coverage, but, alas, upon closer scrutiny leaves many gaps in the high-end disease coverage. She also describes the familiar rhetoric employed by the American Cancer Society's Cancer Action Network, the political action arm of the ACS. ACSCAN President Daniel Smith is quoted as saying that "too many cancer patients are delaying or forgoing lifesaving screenings and treatments because of access problems". This is interesting use of the word "access". We are used to equating coverage with access, but in this case the CAN statement refers to coverage limits set by the insurer, and advocates for swift healthcare reform to remedy this.

But should the intent of healthcare reform be to bring us closer to "Cadillac" coverage? I do not think so: we need to aim for the efficiency of a Prius. The amount of unnecessary and even harmful interventions is staggering and increasing every day. Because currently healthcare is a business that relies on traditional market forces, its implicit purpose is to generate revenue. And while there is tension between purveyors of gadgets and procedures and the payor, a critical approach to coverage is viewed with suspicion by the consumer. Take, for example, screening mammography for low-risk women between the ages of 40 and 50 years: although experts admit that there is little evidence for its value, it is political suicide for the payor not to cover it. The PSA story is similar, as is cholesterol screening, and many other tests and treatments we undertake with blind acceptance.

So, if Mr. Smith is truly worried about access, he and his organization need to take a step back and support evidence-based, rather than politics-based, decision making in healthcare. Universal access should never mean that all of us can get every test or treatment on the market, no matter how marginally effective or ineffective it is. Universal access means using critical thinking to make rational choices.

Bioethicists' litmus test for recognizing rationing is the question "would you do it if it were free?" I would guess that if all of us were well informed about the seamy side of doing "everything", we would refuse many an "evidence-based" recommendation that medicalizes our lives in favor of healthy and happy living. The result? Fewer worried well, less preoccupation with transient ailments, and yes, a lower overall healthcare bill with money left over to cover everyone for what they truly need. And, Maggie, Cadillacs are so 20th century!

Tuesday, July 21, 2009

Politically unpopular taxes -- smacking the wrong dog's nose

Today's Wall Street Journal has a piece entitled "Ten Questions on the Health-Care Overhaul" by Janet Adamy. A number of statements are worth contemplating. For example, Ms. Adamy asserts that "no industry stands to gain more from the changes than health insurers". Certainly, getting their hands on the pristine pool of low-risk young healthy customers will be a boon to their bottom lines. Another is about how a government-run plan might run the poor beleaguered insurers out of business by undercutting them. Well, duh! Is that not how the market is supposed to work -- out with the inefficient and in with the lean?

But what struck me most was the assertion that the Congress would prefer to generate revenue to pay for reform by taxing the rich (incomes over $250,000) than by levying a tax on soda and other sugary drinks, as the latter is thought to be "politically unpopular". Nothing about this discussion strikes me as being more absurd than this logic. Slapping a tax on the rich is like smacking the wrong puppy on the nose for making a puddle in the house -- the action and reaction are completely divorced from each other and therefore no behavior change can be expected.

Here are some facts. Between the 1960s and the millennium, the caloric consumption from sweetened beverages has doubled, adding over 200 empty calories to our daily diet. Since the intake of extra 50 calories/day results in a 1 kg/year weight gain, it does not take a Nobel laureate to connect the dots between sweet drinks and our much lamented obesity problem. And if you believe that obesity is the public health scourge that it is purported to be, as our legislators seem to, is it not then illogical to take off the table a measure that will result in not only restricted exposure to the problem, but also in improved access to the solution?

Perhaps the Congress is thinking that taxing the richest 1% of the American people will reduce their consumption of sweetened drinks enough to mitigate the overall societal obesity epidemic and reduce healthcare costs. If so, they need finance experts even more urgently than the FDA!

Monday, July 20, 2009

Does Public Health need a new name?

Some countries have neither public health infrastructure nor individual healthcare -- think Russia and other former republics of the Soviet Union. Others, like ours, have an oversized enterprise around personal medical interventions, including alternative therapies; public health efforts pale in comparison. Yet others seem to have a desirable balance of both, the Scandinavian nations, for example.

As the most technologically advanced society in the world, what possible reason can the US have for tolerating such poor public health system? After all, it is public health interventions on a large scale -- sewage treatment, clean water, immunization programs -- that deserve most of the credit for our increased longevity over the past century.

The answers may lie in our cultural attitudes of individuality and early adoption. The former eschews anything that may smack of socialism, and in this the "public" in "public health" may be viewed with suspicion. The latter compels us to value the promise of salvation in sexy new gadgetry of modern medicine over the simplicity and self-determinism of such health maintenance tools as eating well, exercising in moderation and getting sound sleep.

So, if I were a marketer, I would suggest that Public Health field adopt some of the high-tech trappings of the healthcare industry and rebrand itself as, perhaps, "Your Individual Plan for Health and Longevity". What, you don't think this will sell? Well, I am not a marketer, of course, and I am probably totally wrong about all this. Or am I?

Friday, July 17, 2009

Costs and access in the healthcare debate

Something unusual happened today -- I was actually nodding while reading a Wall Street Journal article! Today's WSJ reports that the director of the Congressional Budget Office Douglas Elmendorf refuted the ability of the proposed House bills to contain healthcare costs. The CBO Director, while agreeing that the proposals will expand coverage and therefore access, did not see any compromises introduced that would rein in the runaway spending and bring the growth rate in healthcare spending more in line with the inflationary growth.

Indeed, while it is easy for the Democrats to offer more coverage to more people, measures to curtail spending are more politically hazardous: after all, it means cutting the fat out of the system by legislative mandate. And as we already know, this is a terrific opportunity for liposuction! From overused procedures to overpriced products to overpaid executives -- the price tag for this fat could easily pay for millions of Americans' coverage. But of course, it would cut into the incomes and the profits of many of the wealthy stakeholders, who would not accept this without a loud and protracted battle.

These are tough decisions, and lack of political chutzpah on the part of the Democrats to deal with the fat now may jeopardize our chances at meaningful healthcare reform. And if not now, when? Start calling and writing today!

Thursday, July 16, 2009

Will government funded healthcare kill innovation?

During this time of heated debates on Capitol Hill about the future of our healthcare system, many different voices are sounding reasons for keeping the status quo: already best system in the world, working for most, usual hysteria about becoming Nazi Germany or Communist Russia, rationing and denials of necessary services, to name just a few. One frequent refrain from the opponents is that government-run healthcare system will squelch innovation in the manufacturing sector. This faction is worried that we will stop producing game-changing devices and compounds that have been rapidly pouring into the market over these decades of skyrocketing expenditures. Right...

So, let's deconstruct this fear for innovation. If our definition of innovation is putting out me-too compounds that bring marginal, if any, improvements to those that already exist, then we should definitely worry. If, on the other hand, we define innovation as bringing novel entities to market that truly meet health needs, then I think we can sleep soundly knowing that government funded healthcare will not do any worse damage than the manufacturers' risk averse behaviors and focus on returns have done.

Back in 2000 David Horrobin from the UK published a review on pharmaceutical innovation. In this paper he explains that large companies, in order to live up to growth expectations of their investors, need to maintain a certain pace of development. This pace, thus tied closely to marketing goals, is generally fueled by compounds with low risk of failure and high return potential. This translates to a flood of anti-hypertensives, lipid lowering agents, anti-depressants, as well as "life style" therapies (think Viagra). And if you want to bring up oncology therapeutics, where innovation is touted most loudly, ask yourself two questions: 1). how many of the novel compounds were developed in the academia, and 2). what outcomes they have improved for the patients, since many of them, despite the exorbitant price tags, only increase the survival by a couple of months on average.

So, there goes the innovation argument against universal healthcare. Next!

MomsRising healthcare meeting

Yesterday, through, I met with the office of Senator John Kerry (D-MA) in Springfield, MA. Present were Steven Meunier, a Kerry staffer on the issues of healthcare, and 14 adult and 6 future members of MomsRising. We met to discuss how the current healthcare debacle is failing the American families. To supplement the faceless statistics of the 18% of the GDP expenditures with 30% administrative overhead, the 47 million uninsured, nearly 100,000 avoidable deaths annually in our hospitals, we brought personal stories of the system's failures: an uninsured diabetic husband dying of what started as a simple upper respiratory infection, a family contemplating a move to another country due to complex health issues not covered by their current $1,500/month premium plan, a town going bankrupt because of the meteorically rising health insurance premiums.
Now, as a health services researcher and a general skeptic, I know that not all of the stories would have ended differently under universal coverage. Even with accessible and meticulous care people encounter complications and die from their diseases. Even with accessible and meticulous care not all interventions can or should be offered to everyone with a minute chance of benefitting from them. And particularly with accessible and meticulous care our towns will continue to experience fiscal pressures. What I also know is that no one deserves to live with the personal burden of "what if": What if that diabetic had been able to get more prompt and thorough attention? What if people's lives did not need to be disrupted by having to become medical refugees? What if towns could be confident that their fiscal burdens, though considerable, were assuring all of their citizens access to reasonable care?
Ours were just a few of many stories being told by women and men throughout the nation. As Mr. Meunier summarized, we are raising a generation of citizens who are not only skeptical about, but also thoroughly intimidated by our healthcare system and the personal financial burdens implicit in it. This is no way for the wealthiest country in the world to promote health maintenance. Although our stories are not infusing the Washington economy with $1.4 million daily, and ours are not household names in your offices, this is your opportunity, Congress, to do the right thing. Our future depends on it!

Tuesday, July 14, 2009

Pork in the age of the superbug

Did you know that 70% of all antibiotics used in the US are administered to livestock on industrial farms for the purpose of stimulating growth, not to treat diseases? And they are not administered under a veterinarian's supervision. We can only guess what proportion of the 1,000,000 hospitalizations with resistant infections and of roughly 90,000 deaths attributed to these infections can be blamed on this antimicrobial free-for-all. The FDA and other agencies have been unwilling to ban such practices, and, understandably, the meat industry has not protested.

Finally, Representative Louise Slaughter (D-NY), chair of the House Rules committee, has proposed a measure to ban this egregious practice, the NYTimes reports. Her proposal would "ban seven classes of antibiotics important to human health from being used in animals" and would "restrict other antibiotics to therapeutic and some preventive uses". It is about time the Congress took up this public health issue.

In an attempt at obfuscation, a spokesman for the pork producer's trade group pointed out that there are no good studies linking this rise in resistant infections in humans to use on animal farms. Really? Could it be because the meat industry has been ever so forthcoming with their usage and other data? For me there is plenty of circumstantial evidence and biologic plausibility, and, as with cigarette smoking, it will be virtually impossible to design studies that can unequivocally demonstrate attribution.

In this too we need to learn from the Europeans -- precautionary principle should reign. Let us not allow pork to throw us back to pre-antibiotic era.

Will Viagra be covered under the public option?

NPR's Julie Rovner today reports that the healthcare reform legislation is encountering difficulties from that perennial third rail of healthcare policy: abortion. The vocal anti-choicers believe that no tax dollars should go to funding elective abortions, and have vowed not to sign any legislation that includes such funding. They state that current government-funded and subsidized plans (e.g., the one that members of Congress get) pay only for an abortion to "save the life of the mother, or in cases of rape and incest".

The monkey wrench is that most private plans do not have restrictions on reproductive health coverage and include abortion. So, the legislative restriction proposed by the anti-choicers would take away coverage that exists today. They are of course worried that, given unlimited access to elective abortions, an unprecedented tsunami of abortion-seeking women will beat down the doors of hospitals and healthcare systems, waving their burning bras and demanding this highly desirable and popular procedure! Or is this just a tactic to derail any meaningful discussion of healthcare reform? Hmm, I am suspicious.

Has anyone heard whether coverage for Viagra is to be curtailed as well?

And here are the 19 House Democrats that have signed on to this wedge (courtesy of Tim Bernhard):
Dan Boran (D-Okla.), Bart Stupak (D-Mich.), Colin Peterson (D-Minn..), Tim Holden (D-Pa.), Travis Childers (D-Miss.), Lincoln Davis (D-Tenn.), Heath Shuler (D-N.C.), Solomon Ortiz (D-TX), Mike Mclntyre (D-N.C.), Jerry Costello (D-Ill.), Gene Taylor (D-Miss.), James Oberstar (D-Minn.), Bobby Bright (D-Ala.), Steve Driehaus (D-Ohio), Marcy Kaptur (D-Ohio), Charlie Melancon (D-La.), John Murtha (D-Pa.), Paul Kanjorski (D-Pa.), and Kathleen Dahlkemper (D-Pa.).

Monday, July 13, 2009

Precaution and your 401K

It is estimated that there are over 80,000 potentially toxic chemicals bathing us in our daily lives, only 200 of which have been evaluated for safety by the government agencies. The debate over how these chemicals come to market goes something like this. Manufacturers argue that these chemicals have not been definitively proven to cause disease and, furthermore, restrictive regulations will drive them out of business with the commensurate loss of jobs, revenue and products. Environmental and safety advocates counter this by asking why should we wait for people to die from these exposures before we ask these questions and investigate their potential ill effects? The latter is called the "precautionary principle" in environmental science. The European Union has largely adopted this philosophy in the way they deal with marketing of new products. Once again, the US lags behind. Why? Economics! Is it cynical to ask, since we have the most financially robust healthcare enterprise in the world, why focus on prevention when our 401Ks will do so much better with funding thrown at finding the cure?

What is the right balance of precaution and economic interests and who suffers from the imbalance of the two in either direction?

Friday, July 10, 2009

Tweets from the OR

Yesterday's NY Times Tara Parker-Pope' blog post on tweets from the OR -- what a great way to use this new technology. During the operation on a 10-year-old Mongolian burn victim the Children's Mercy Hospital's public information officer tweeted the progress of the surgery to both, the boy's family in the waiting room and in Mongolia (with family's permission the tweets were made public).

What an exciting and useful potential application for Twitter!

G8 climate talks -- sandbox power struggle

Do your kids get into each other's space and start to bicker incessantly? Mine do. And inevitably it ends up in "Mama, he hit me" or "Mama, she pinched me". I always say to them to work it out on their own, but they come back with "he started it" or "she started it". And I, as patiently as I can (not always very patiently), come back with "it takes two to tango". And by now they know I do not care who started it, but hold them both responsible and expect each to take his and her piece of the responsibility. Wouldn't you think that diplomats can do this?

Well, think again. NPR today reported that the G8 climate talks are essentially gridlocked. The developing nations, with China as the biggest producer of Co2 emissions, claim that they cannot afford to cut just now, as they are hooked on the cheap fossil energy fueling their explosive growth. And the developed world, responsible for a disproportionate share of the pollution, thinks that the targets requested of it are too aggressive in the short term. Are they kidding?

Some scientists think that we are already beyond the point of no return, and that we are on an irrevocable trajectory to destruction. But as a scientist myself I understand that their models are just probabilities of future events based on their current assumptions. And probabilities are never absolute (until they happen, of course). So, I prefer to be an optimist and be proven a fool rather than a pessimist and be proven right (this is my fortune cookie wisdom). So, I believe that there is still time for us to act at least to mitigate if not reverse this environmental debacle. And the world politicians are engaged in a sandbox power struggle of "who started it"? I find this appalling!

I appeal to everyone to do their part. Tell your Members of Congress, tell President Obama, tell your boss, tell your family that we are all in this together and we need to act now before it is too late! I will pledge to continue to work towards reducing the carbon footprint of medical waste, in addition to that of myself and my family and friends. I will call and write to my elected representatives, including Mr.Obama. What are you going to do?

Tuesday, July 7, 2009

Is useless harmful?

An interesting paper appeared in last week's issue of the Journal of the American Medical Association (JAMA) entitled "Exploring the Harmful Effects of Health Care" by Kilo and Larson. It was a call to action by two very astute researchers to start setting an agenda for quantifying the full benefit-harm proposition of healthcare in the US. They went so far as to propose a taxonomy for this issue, consisting of direct and indirect harms. Direct harms are defined as adverse physical and emotional effects of healthcare encounters, while indirect ones are "collateral effects on individuals and communities not directly involved in care".

This exploration is very timely as we engage with each other and with policy makers in health reform discussions. We hear a lot about hospital-acquired complications, as well as quality deficits that have resulted in 44,000 to 98,000 unnecessary deaths annually in the US hospitals. We are inundated with information on the emergence of superbugs and the threat they present to humankind. We are very aware of the need to screen for and treat aggressively such public health scourges as diabetes, hypertension and obesity. Ostensibly, we have a lot of information already on what needs to change in our approach in order to improve quality and efficiency of the healthcare system.

Believe it or not, this is a mere tip of an enormous iceberg that is about to challenge the Titanic that is our healthcare system today. While it is clear that some of the answers lie in improving the quality of delivery so as to prevent unnecessary morbidity and mortality in our institutions, this single-pronged approach promulgated by vocal policy think tanks and adopted by most if not all reimbursing and regulatory bodies is doomed to fail. The problems lie far upstream from the fateful contact with this healthcare system. What I mean by that is that we need to examine our assumptions about risks and benefits of the very interventions that bring us to this precipice. Although there is some evidence that it is feasible to control pharmacologically marginally elevated blood pressure in an individual, the evidence of the benefit of such control is scarce. Furthermore, in our zeal to stamp out this silent killer, we generally fail to stop and weigh the potential harms of such treatment against the miniscule, if any, benefits to essentially healthy people. This logic can apply to a wide range of currently recommended "evidence-based" interventions, ranging from the annual physical exam to, you guessed it, screening mammography. And you already know how I feel about the risk that a false positive presents to your health!

One final thought about indirect harms. Yes, we need to think hard about whether or not it makes sense to spend 60% of all healthcare dollars in the last 6 months of life, and yes we would probably agree that there are better ways to allocate the limited healthcare resources. But indirect harm has another more insidious face as well. The famous Roemer's rule states that "a built bed is a filled bed", meaning that the availability of a resource encourages its use. In this context, what is the environmental impact of producing healthcare implements that promise a generous return on investment (through our woefully misaligned incentives), from MRI machines to new hospital facilities, implements that may be promoting at best useless and more likely harmful overuse? And what about the medical waste that is created unnecessarily by this overuse and the polluting chemicals that form in the process of its disposal?

Once again I find myself gravitating toward that adage: "less is more". In this season of healthcare reform buzz let's think hard about the consequences of inaction or wrong action. Because useless in this instance is not just unnecessary, but potentially deadly.