August 29th, 2009 by KevinMD in Better Health Network, Opinion
Tags: Biotechnology, Demonize, Michael Kirsch, Pharmaceuticals, Research
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by Michael Kirsch, MD
Demonizing the pharmaceutical industry has become a parlor game for many who enjoy the challenge of shooting at an oversized target. Scapegoating Big Pharma? Now, that takes guts.
Never mind the gazillions they spend on research and development to create tomorrow’s treatments for cancer, arthritis, depression, infectious diseases, heart attacks and strokes. I know that drug industry executives are not all eagle scouts whose mission is solely to save humanity. But, they are not an evil enemy that we need to contain like the “swine flu” pandemic. Sure, they make a profit, and they deserve to. Drugs cost multiple millions of dollars to develop, and most of them never make it to market. Those that do, after years of testing and F.D.A. review, can be summarily shut down when unexpected serious adverse reactions are suspected. In these cases, there may be no actual proof that the medicines were responsible for the ‘side effect’.
I’m not suggesting that we demand airtight proof before issuing drug warnings, only that we beware of what happens if drug company profits can be decimated with the stroke of a pen. Playing rough with the drug companies may appeal to our populist sensibilities, but it can go too far and stifle innovation.
Drug companies need the promise of large profits if they are to take the risks inherent in developing new and novel medicines for all of us. What other business would invest in a new product or technology without the potential for substantial financial gain? Before we advocate price controls for medicines or shortening intervals of patent protection, consider the side effects of this clumsy approach. If we hit Big Pharma too hard, then they will play it safe and churn out lots of drugs that we don’t really need.
Which would you rather they invest in? Another drug for heartburn that is no better than all the others on the shelf, or a vaccine to prevent cancer?
If they succeed in the latter endeavor, I hope they earn hundreds of millions of dollars. This will still be less than the number of lives they will save.
Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.
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*This blog post was originally published at KevinMD.com*
August 28th, 2009 by Jonathan Foulds, Ph.D. in Better Health Network, Health Policy, Opinion
Tags: Death Panels, Healthcare reform, Scotland, smoking, smoking cessation, US
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I’ve been bemused by the debate on healthcare reform taking place in the U.S. right now. I used to thing that the single topic that people talk the most nonsense about is sport. You know, my sport is better than your sport, my team is better than your team etc. All good fun, but usually nonsense. And then I’ve watched pundits on TV and heard ordinary Americans talk about healthcare reform and wow….its got the sports conversations beaten for absolute gibberish.
So despite a reluctance to get involved because I recognize it’s an extremely complicated issue, I now feel compelled to say a few words. Part of it is because unlike most of the people expressing an opinion, I’ve worked and been a patient in the healthcare system in a country with “socialized medicine” (UK) and I also currently work and am sometimes a patient in the United States healthcare system.
So lets start off with a few basics. The United States has some of the most highly trained healthcare staff and by far and away the best healthcare technology in the world. Just to give an example, there are more scanners (MRI, PET, SPECT etc) within a 15 mile radius of my office in central New Jersey than in the whole of Scotland (population about 5 million). And the United States spends far more on healthcare than any other country in the world. But despite that vast wealth of resources that befits the worlds greatest economic power, the United States falls way down the league table on basic objective measures of health outcomes, and similarly down the league on patient satisfaction with healthcare. There are really very few people, (who have looked further than the end of their own nose into this issue) who don’t acknowledge there’s a very serious problem.
For many in the United States, the problem is not so apparent. So if, like me, you and your immediate family are fortunate enough to be relatively healthy, and to be covered by a relatively good employment-based health insurance package, then it may seem OK. It’s when you get very sick, or are unfortunate enough to lose your job, that some of the basic problems with the U.S. system become more apparent. It’s when you get sick that you may find that your policy doesn’t cover the kind of treatment you need, or has a high deductible (amount you have to pay before the insurance takes over). And its when you lose your job and have to start paying out of pocket for health insurance that you realize it is extremely expensive. And of course if you have a gap in coverage and get sick then the new insurer may refuse to cover your “pre-existing condition”.
To me, the single time in your life when you don’t want added financial stress is when you are sick. But many aspects of the U.S. system direct coverage and services to those who need it least (healthy, young ,well insured employees) and become a nightmare for those who need good healthcare most (aging, sick unemployed people). Now when you talk to people in countries like Britain about this, they are generally appalled and quickly see the problem. But one of the things that has surprised me most about the debate in the United States is that a significant proportion of people here seem to really believe that the old “survival of the fittest” philosophy is appropriate here. The attitude seems to be something like: “If someone gets sick and didn’t have the fore-thought to get adequate health insurance to cover the treatment, then that was their own fault. Why should I work my ass off to look after my family and their healthcare needs for some lazy unemployed person to get healthcare for free?”
So somewhere deep in the psyche of many Americans there is a basic belief that healthcare (insurance) is just like auto insurance….something we are all individually responsible for, and if we cant afford it, that’s tough. Many do not believe that healthcare access for all is a basic requirement of a civilized society (like roads and schools).
So President Obama and others who are currently trying to change the U.S. healthcare system have a tough task ahead. It is currently being made much tougher by some bizarre reporting on this topic by the right wing media (Fox etc). We hear weird stories about “death panels” of government bureaucrats who will decide which sick people should have the plug pulled on their healthcare under government healthcare. We hear weird stories that in countries with socialized medicine it’s the government, not the doctor who decides on what treatment is provided. Well I can tell you that I never saw “Big Brother” interfering in doctors’ clinical practice until I came to the United States. In this country it is bureaucrats working for health insurance companies, generally with no medical qualifications, who deny coverage for appropriate medical treatment hundreds of thousands of times a day.
Often coverage is not denied on clinical grounds, but rather for a whole series of “technical” reasons (wrong diagnostic code, doctor not part of that health insurance plan, pre-existing condition, patient already used annual entitlement for that type of care, patient had that treatment already for longer than policy will pay, treatment carried out at a non-approved facility [go to one 30 miles away], patient hasn’t completed the 6-monthly confirmation of details form, health insurance company doesn’t cover that type of illness/service etc etc). But the underlying strategy is to make it so difficult to get a treatment covered and paid for, that fewer people will go for treatment, and fewer doctors will provide certain procedures because it is so much hassle for them to get paid for it. So the insurance companies hire more people to try to find ways to deny coverage and payments, and doctors have to employ billing specialists to figure out how they can get paid for providing treatment. And the result is an extremely inefficient beaurocratic mess.
Surely a country like the United States can do much better than this?
Now you might be wondering what any of this has to do with smoking? Well one link is that many health insurance policies in the United States do not cover a range of interventions they call “preventive” or “wellness enhancing” interventions. Frequently that means that patients cannot get tobacco dependence treatment (medicines or counseling) covered and so they don’t get the treatment. This is despite the fact that such treatment is one of the most cost-effective clinical interventions available. So an important part of the new proposals for healthcare reform is an increased emphasis on preventive healthcare. This is certainly a step in the right direction.
This post, A Scottish View Of US Healthcare Reform, was originally published on
Healthine.com by Jonathan Foulds, Ph.D..
August 26th, 2009 by DrRob in Better Health Network, Opinion
Tags: Denial, Denial Of Coverage, Health Insurance, Healthcare reform, Internal Medicine, Primary Care, Recitivism
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Something touched a nerve yesterday. I kind of lost my composure when someone tried to defend the insurance industry and responded out of emotion – perhaps putting aside some reason in the process.
I used to get mad at myself or embarrassed when this happened, but now I stand back and try to analyze my reaction. What is it that touched a nerve in me? Why did I feel so strongly? We don’t feel things without reason, and my reaction doesn’t necessarily betray weakness on my part, it shows the depths of my emotion. That passion usually comes from something – most of the time it is personal experience; and my personal experience says that insurance companies are causing my patients harm. That makes me angry.
I don’t think the people in the insurance industry are bad people. I think vilifying people is the easy way out. The people there feel like they are doing the right thing, and are no less moral than me. But I do not think the way to fix our system is through letting them do their business as usual in the name of “free market.” Defending the current system of insurance ignores some obvious problems in our system:
1. They are financially motivated to withhold services
If you hire a contractor to work on your house, how wise is it to pay them 100% in advance? You have just given them financial incentive to do as little work as possible, as it will maximize their profits to do so. The insurance industry is in such a situation; despite any good intention, they are put in a position to decide between profits and level of service. It is much better to pay more for better service, not worse; but that is what we have done with health insurance companies.
2. They have been given the ability to withhold services
If all United Health Care (for example) did was to provide insurance, they would not be vilified as they are. But since the only data available for medical care was the claims data they hold, they were put in a position to control cost. This was sensible initially, as they had both the data and the means (denying unnecessary care) of cutting cost. It’s OK that women aren’t kept in the hospital for a week after having a baby. It’s OK that I can’t prescribe expensive brand-name drugs when there is a reasonable generic alternative. There was a whole lot of fat to cut, and they did a good job cutting that fat.
The problem came when all the fat was gone and they were used to big profit-margins. Once there was not any more unnecessary care to cut, they had two ways to keep their profit-margins: increasing premiums or cutting services. They did both. Both of these have hurt my patients.
- Patients have had premiums increased or have been dropped because they were diagnosed with medical problems. I have had patients beg me “don’t put that in my record,” as they know a diagnosis of diabetes or heart disease will be disastrous. I am then caught between the pleas of my patients and the demands of honestly practicing and documenting my care.
- I do what I can to follow evidence-based standards, but there are times when people fall out of the norms. Medicine is not science, it is applied science. This means that I am trying to take an individual and somehow match them with the scientific data. Sometimes it works, but everyone is different. If something is true 90% of the time, 10% of the people will be exceptions to the rule. I have repeatedly been told by “gnomes” (people with minimal medical education who sit in front of a computer screen with a protocol for care) what “good medicine” looks like. They see things as black and white when it is just not that way. This has caused people to be unnecessarily hospitalized, it has required them to get unnecessary tests to follow their rules. There is no arguing with people in front of computers.
3. They covertly ration
Dr. Rich Fogoros (whom I recently met) has coined this phrase to explain what happens in our system. Because it doesn’t look good to deny necessary care, insurance companies (including government-run ones) resort to making things exceedingly complex. This makes it look like care is being offered, but not taken advantage of. What does this mean?
- The burden of proof is put on the provider to show the tests ordered are necessary. The assumption is that a test will be denied unless the doc can prove otherwise.
- Tests are sometimes inappropriately denied. They then can be appealed, but the appeal process is even more difficult than the initial approval process, and so some people give up. Every time someone gives up, less is paid out by the insurance company and their profits go up.
- The rules for coding and billing are so complex, that it is very easy to make mistakes. This means that an appropriate test ordered by a doctor that is not perfectly coded doesn’t get paid for. The patient gets the bill and must get the doctor to appeal the denial. This appeal process, again, is difficult.
Because of this, I have to hire staff whose sole task is to learn all of the rules of the different insurance carriers (including public ones) and then play the game properly with them so that we get as few denials as possible. I probably spend $70-80 thousand per year to deal with the frustratingly complex system we have.
————
I have health insurance. I do understand why it needs to exist, but I also see how harmful the current state can be to my patients. I get frustrated with Medicare and Medicaid as well, but that is not my point. Just because government run insurance has problems doesn’t do anything to change the problems with private insurance. The fact that you can be killed by firing squad doesn’t make the gallows any better.
The cost of care has gone up dramatically over the past 10 years while my reimbursement has dropped. Where is that extra money?
But the system is very broken right now. It needs to be fixed. Things need to be changed in both the private and public sector. When I was in DC I made the point that our ship is sinking and we are arguing about who will be the captain. The problems in our system are not simply who is writing the checks.
Honestly, I don’t really care who writes the checks. All I want is for the system to reward good care and to stop hurting my patients. Those who deny the reality of either of these problems will invariably draw my ire.
*This blog post was originally published at Musings of a Distractible Mind*
August 25th, 2009 by DrRich in Better Health Network, Opinion
Tags: comparative effectiveness research, Death Panels, HR 3200, Republicans, Sarah Palin
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When Sarah Palin uttered the fateful words, “Death Panels,” she unleashed the holy wrath of the great unwashed masses, and as a result caused many of our more complacent legislators to abruptly bestir themselves into a higher state of arousal, if not outright agitation. Palin’s accusation caught more than a few of them utterly unawares, and embarrassingly flatfooted.
They felt, no doubt, like they were in that dream where you unaccountably find yourself naked in a crowd. But this time, rather than reaching to hide their sadly exposed nether parts, they reached instead for their pristine copies of HR 3200. One could almost pity them, desperately rifling through the 1100 virgin pages, wondering whether perhaps they should have tried to read that monstrosity earlier after all, and muttering to themselves, “Death panels? This damned thing has death panels?”
But DrRich is here to reassure them. First, as he has recently pointed out, there was in fact no reason for them to waste their time trying to read HR 3200. It was not designed for reading, comprehensibility, or (for that matter) imparting any actual information of any sort.
And second, HR 3200 contains no death panels. (In their state of stark panic, of course, and anxious to rid the bill of anything that might smack of death panels, our legislators quickly moved to strike Section 1233 from the bill, apparently because that section contains the phrase “end-of-life care.” But actually, Section 1233 talks about end-of-life counseling, and not death panels. Nothing in HR 3200 creates death panels.)*
The very notion of death panels seems to have many supporters of healthcare reform nonplussed. How can someone as inarticulate and obviously illiterate as Sarah Palin get away with accusing our highly-educated healthcare reformers of setting up such a thing as death panels? Really, what are death panels anyway? And even more perplexingly (since, after all, Republicans are capable of anything), why do so many Americans believe her – even, apparently, hundreds of thousands of Americans who were enlightened enough to vote less than a year ago for President Obama?
This question ought to greatly concern any of our elected representatives who support healthcare reform and who plan on being returned to Congress.
When Sarah Palin said, “Death Panels,” she was dropping one last, tiny crystal into a supersaturated solution. Her words took what had been an amorphous and even chaotic sense of unease about healthcare reform, and immediately crystallized it into an organized latticework of directed rage and fear. So the real question (for politicians hoping to seek re-election) is not how Sarah Palin came to be savvy enough to know just the right words. (Perhaps she was just “lucky,” or perhaps – and DrRich suspects this is the real explanation – she is a lot smarter than her critics allow.) Rather, the real question is: What put the rabble in such a supersaturated state to begin with? Why did the absurd-on-its-face idea of “death panels” so resonate with them? What made those words galvanize their shapeless disquiet into a solid mass of resistance?
DrRich is very sorry to have to tell his friends of the Democratic persuasion the sad truth – it was President Obama who created this circumstance. Sarah Palin may have named the death panels, but before she ever thought of the phrase, President Obama had already described them in some detail.
He described their function, how they would operate, and who they would target. During the past 6 months President Obama has actually offered several short discussions on what a “death panel” might be expected to accomplish. But perhaps the most instructive example is the one he gave on ABC television during his June 24 National Town Hall meeting.
DrRich refers, of course, to the famous question about the 100-year-old woman who received a pacemaker. The questioner pointed out that her grandmother had badly needed a pacemaker, but had been turned down by a doctor because of her age. A second doctor, noting the patient’s alertness, zest for life, and generally youthful “spirit,” inserted the pacemaker despite her advanced age. Her symptoms resolved, and Grandma continues to do well 5 years later. The question for the President was: Under an Obama healthcare system, will an elderly person’s general state of health, and her “spirit,” be taken into account when making medical decisions – or will these decisions be made according to age only?
President Obama’s answer was clear. It is really not feasible, he indicated, to take “spirit” into account. We are going to make medical decisions based on objective evidence, and not subjective impressions. If the evidence shows that some form of treatment “is not necessarily going to improve care, then at least we can let the doctors know that – you know what? – maybe this isn’t going to help; maybe you’re better off not having the surgery, but taking the pain pill.”
(DrRich will give President Obama the benefit of the doubt regarding his suggestion that a 100-year-old women who needs a pacemaker might be better off with a pain pill. Despite the way he is portrayed on the cover of Time Magazine, Mr. Obama is not actually a doctor, and cannot be expected to understand that using a “pain pill” to treat an elderly woman who is lightheaded, dizzy, weak and possibly syncopal because of a slow heart rate might justifiably be considered a form of euthanasia rather than comfort care. DrRich does not believe the President was intentionally suggesting the old woman’s death should be actively hastened by means of a pain pill. At the same time, DrRich’s advice to this still-spry 105-year-old Grandma is: since pacemakers usually need to be replaced every 6 – 7 years, you’d better think about having your 5-year-old pacemaker replaced right now, before the Obama plan has a chance to become law.)
President Obama’s answer in this case tells us several things. 1) There will be a panel, or commission, or body of some sort, that is going to examine the medical evidence on how effective a certain treatment is likely to be in a certain population of patients. 2) This (let’s call it a “panel”) panel will “let the doctors know” whether that treatment ought to be used in those patients. (”Letting the doctor know” is a euphemism for “guidelines,” which itself is a euphemism for legally-binding and ruthlessly enforced directives.). 3) “Subjective” measures (such as a physician’s clinical judgment as to an individual’s likelihood of responding to a therapy as the panel says they will – or, for that matter, a person’s “spirit”) ought not to influence these treatment recommendations, since that kind of subjective judgment is what got us into all this fiscal trouble in the first place. 4) But being that our government is a compassionate and caring one, palliative care will be made available in the form of pain control, even while withholding potentially curative care.
So, according to the President, we will have an omnipotent “panel,” acting at a distance and without any specific knowledge of particular cases, that will tell a doctor whether he/she can offer a particular therapy to a particular patient – or whether, instead, to offer a “pain pill.” His description of this process, offered with variations over the past several months in several venues, has obviously made quite an impression among the people. Of course, Mr. Obama is widely known to be a gifted communicator.
In any case, all that remained was for Sarah Palin to give the President’s panel a catchy name. And when she did, the American people (without reading HR 3200 or any other piece of legislation) knew exactly what she was talking about. They knew, because President Obama himself had been spelling it all out for them in plenty of detail for six months.
Indeed, it seems to DrRich that, if not for Mr. Obama’s having so carefully laid the groundwork, Palin’s accusations of “death panels” would have fallen flat. It would have been regarded by most people as the absurdity Democrats insist that it is, rather than the epiphany it turned out to be.
* There are no death panels in HR 3200 because creating them there would have been entirely superfluous. If we are to have death panels, or any entity that might pass as one, the provision for such a panel is already the law of the land. It was made so earlier this year (conveniently, before anybody started paying attention) in the Stimulus Bill, which created the Federal Coordinating Council for Comparative Effectiveness Research.
DrRich has described before how the CER Council will perform cost-effectiveness calculations, then coerce physicians, through one form of federal subterfuge and intimidation or another, to employ the least expensive therapies (thus enforcing “cost”, while shouting “effectiveness”).
It is called a CER Council, and not a death panel. But if you should develop a fatal illness which you might have survived had you been allowed to receive a treatment that the Council has deemed cost-ineffective, then you might be forgiven for thinking of the CER Council (from your insular, personal, narrow-minded, self-interested point of view), as a death panel. But there are no death panels in HR 3200, and Sarah Palin should be ashamed of herself for suggesting otherwise.
*This blog post was originally published at The Covert Rationing Blog*
August 22nd, 2009 by Happy Hospitalist in Better Health Network, Opinion
Tags: Health Insurance, Health Insurance Reform, Healthcare reform, System Reform
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Boy if that statement doesn’t hit the nail on the head.
Talking to Cortese this week, I heard two themes that cut to the heart of the debate. First, he thinks Obama has made a mistake in moving toward the narrower goal of “health insurance reform” when what the country truly needs is health system reform. Imposing a mandate for universal insurance will only make things worse if we don’t change the process so that it becomes more efficient and less costly. The system we have is gradually bankrupting the country; expanding that system without changing the internal dynamics is folly.
Let me give you the truth of our current reality. We as a nation are headed for a devastating bankruptcy at the hands of our current health insurance model. A model that pays for everything (of substance) and passes on those costs to current and future generations.
Obama’s push for health insurance reform will do nothing to save America’s model that pays for everything (of substance) and passes on those costs to current and future generations.
The argument, as I see it, is not that a lack of insurance is bankrupting our country, but rather the model of insurance itself. Getting more of the same won’t make health care less expensive, it will make it more expensive. And ultimately, if we keep paying for things the way we pay for things now, there won’t be any money left for anyone.
Some people argue that spending money now with universal access will create a healthier and cheaper to insure America. To that, all I have to say is look to the history of the last 50 years. Medicare did not make health care cheaper. It has, for the last 50 years lead to a devastating economic death spiral. FREE=MORE is bankrupting our country. The model of insurance is bankrupting our country. The storm on the horizon will be the death of America, unless something changes, and soon.
I think the whole current nonsense debate is a travesty both from the Republicans and the Democrats. Opponents and proponents are both focusing on the wrong issues at hand. The issue is cost. If you can’t control costs, nothing else matters.
Doctors every where should embrace a system of delivery that encourages value and quality. The ones that will fight you tooth and nail are the ones that are ripping off America with their pretend care. The bad ones will suffer as will.
The physicians most expensive procedure is the pen. If doctors can’t lead the way toward cost effective care, then they should get out of the way while others do. Because if we as physicians don’t do something, we will have spent all the Treasury’s money for all future generations. And we will have no one to blame but ourselves.
Thanks again to Are You A Doctor for pointing me to this article.
*This blog post was originally published at A Happy Hospitalist*
