An American plan to help the uninsured, restore Medicare’s fiscal soundness, and preserve medical excellence.
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Dr. Blumenthal conceded that “government controls on health care spending are associated with longer waits for elective procedures and reduced availability of new and expensive treatments and devices.” But he called it “debatable” whether the timely care Americans get is worth the higher cost.
Ask a cancer patient and you’ll get a different answer. Delay lowers your chance of surviving cancer. Women in the U.S. are more likely to have regular mammograms than in other developed countries, according to the Commonwealth Fund. Their breast cancer is detected sooner. They are also treated faster and have higher survival rates, according to the Concord 2008 Five Continent Study. The figures reflect all American women, not just those with insurance.
Another key administration figure committed to cost cutting is Dr. Ezekiel Emanuel, a health policy advisor in the Office of Management and Budget and brother of Rahm Emanuel, the president’s chief of staff. Dr. Emanuel says that the usual recommendations for cutting costs (often urged by President Obama) are window dressing: “Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records, and improving quality are merely ‘lipstick’ cost control, more for show and public relations than for true change.” (Health Affairs, February 27, 2008.) Dr. Emanuel is right. A December 2008 Congressional Budget Office report confirms that none of these pain-free strategies will yield much savings.
True change, writes Dr. Emanuel, must include reassessing the promise doctors make when they enter the profession, the Hippocratic Oath. Amazingly, Dr. Emanuel criticizes the Hippocratic Oath as partly to blame for the “overuse” of medical care: “Medical school education and post graduate education emphasize thoroughness,” he wrote. Physicians take the “Hippocratic Oath’s admonition to ‘use my power to help the sick to the best of my ability and judgment’ as an imperative to do everything for the patient regardless of the cost or effects on others.” (Journal of the American Medical Association, June 18, 2008.) Of course that is what patients hope their doctors will do.
But Dr. Emanuel wants doctors to look beyond the needs of their own patient and consider social justice. They should think about whether the money being spent on their patient could be better spent elsewhere. Many doctors are horrified at this notion, and will tell you that a doctor’s job is to achieve social justice one patient at a time.
Dr. Emanuel also blames high U.S. spending on standards Americans take for granted. “Hospital rooms in the United States offer more privacy…physicians’ offices are typically more conveniently located and have parking nearby and more attractive waiting rooms.” (Journal of the American Medical Association, June 18, 2008.)
The administration’s health advisors would like to see a European-style government-controlled environment of medical scarcity. Do Americans want to copy Europe?
Part of the framework for such controls was slipped into the stimulus legislation signed into law by President Obama on February 17. The legislation sets a goal that every individual’s medical records will be entered into an electronic data system. More importantly, your doctor will be guided by electronically delivered protocols on what is “appropriate” and “cost-effective” care. Doctors who are not “meaningful users” of the system begin facing financial penalties in 2014. Patients insured by Medicare and Medicaid will be affected first, because the penalties are imposed by these programs. But private insurers historically have followed Medicare’s lead.
How much leeway will doctors have? That’s hard to say, because the legislation gives the Secretary of Health and Human Services total discretion to define “meaningful user” and to make the definition “more stringent” over time.
Medical knowledge is evolving so quickly that helping doctors keep up by delivering information on best practices would be beneficial. But telling doctors what to do for the sake of cost control in dangerous. The RAND Corporation, a nonpartisan research organization, found that often physicians did not give patients the optimal treatment for their condition. But over-treating patients was seldom the problem (only 11 percent of the time). Failing to give patients a needed treatment was four times as big a problem (46 percent of the time). That’s why prompting doctors to do the right thing will help patients but not curb spending.
Dr. Blumenthal agrees: “Improved medical decision making is as likely to increase expenditures for underused services as it is to reduce expenditures for overused services.” (New England Journal of Medicine, 2001). To control spending as President Obama promises, doctors will have to be instructed to provide less care. Government controls are a blunt instrument. RAND reported that Canada posts lower rates of cardiac procedures than the U.S. almost entirely by restricting their use for patients age 65 and older — the time of life you’re likely to need it.
In March, President Obama appointed Dr. David Blumenthal to head the system of computer-guided medical care as the National Coordinator of Health Information Technology. Just days later, Dr. Blumenthal settled a debate on whether the system will control doctors’ treatment decisions. In an article in the New England Journal of Medicine (April 9, 2009), Dr. Blumenthal stressed that the real importance of computers is to deliver “embedded clinical decision support,” a euphemism for computers telling doctors what to do. He predicted that if controls are too tight, physicians may resist the government encroaching on their treatment decisions: “many physicians and hospitals may rebel — petitioning Congress to change the law or just resigning themselves to…accepting penalties.” Dr. Blumenthal’s latest article corrects CNN’s Elizabeth Cohen and FactCheck.org’s Lori Robertson, who insisted incorrectly that nothing in the stimulus legislation indicated “the government is going to tell your doctor what to do.”
Also slipped into the emergency stimulus legislation was substantial funding for a Federal Council on Comparative Effectiveness Research, a board with a troubling mission. Studying which medication or device works best is obviously a good thing, but comparative effectiveness research is generally code for limiting care based on the patient’s age. Economists are familiar with the formula already in use in the U.K., where the cost of a treatment is divided by the number of years (called QALYS or quality-adjusted life years) the patient is likely to benefit. In the U.K., the formula leads to denying treatments for age-related diseases because older patients have a denominator problem — fewer years to benefit than younger patients with other diseases. In 2006, older patients with macular degeneration, which causes blindness, were told that they had to go totally blind in one eye before they could get an expensive new drug to save the other eye. It took nearly two years to get that government edict reversed.
When comparative effectiveness research appeared in the stimulus bill, Rep. Charles Boustany Jr., a Louisiana heart surgeon, warned to no avail that it would lead to “denying seniors and the disabled lifesaving care.” Later, Sen. Jon Kyl introduced an unsuccessful amendment that would have barred the federal government from using the research to deny coverage for certain treatments. Now that comparative effectiveness funding is the law, President Obama recently appointed Dr. Emanuel to the Council, and he is likely to play a leading role because of his extensive writings on rationing care based on a patient’s age.
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