Doubled over in pain, you stagger into the emergency room and are diagnosed with acute appendicitis. A surgeon leans over your stretcher:
Surgeon: You need an appendectomy.
You: What are my options?
Surgeon: Either I take out your appendix or you die.
Now that’s a conversation people can understand. But what if, instead of whisking you up to the operating room, the surgeon kept talking and invited a few other people into the discussion?
Surgeon: Do you think I should take it out by an open operation or laparoscopically?
You: Huh?
Laparoscopy equipment salesman: You know, cutting you open the old-fashioned way and leaving a big scar or having a tiny incision. Laparoscopy is much better than the open procedure.
Guy who sells scar-removal cream: Wait a minute. Better for whom? Laparoscopy takes fourteen minutes longer.
Hospital administrator: But hospital stay is reduced by 0.7 days on average, patients have less pain, and you can return to work sooner.
Surgeon: Laparoscopy costs more than an open operation while you’re hospitalized but less once you’re home. What’s your co-pay?
You: Doc, my belly’s hurting a lot more now.
Guy who owns shares in a drug company: What if we just treat him with antibiotics?
Surgeon: Don’t be silly. His appendix could burst.
Funeral director: What about doing nothing?
Very smart people are zoning out of the health care reform debate because they think it’s just too complicated.
The latest poll out today from the Kaiser Family Foundation, a nonpartisan health-care-policy research organization unaffiliated with Kaiser Permanente, says only 27 percent of the public has been following the health reform debate closely. Despite this, more than half (56 percent) of Americans think health reform is more important than ever.
Simply put, there are four main goals of the legislation:
Coverage expansion and subsidies. This is where most of the estimated trillion dollar price tag over ten years would go – to expanding Medicaid for uninsured and lower income people and to help people who can’t afford it pay on a sliding scale for insurance through new health insurance exchanges.
Insurance market reforms. This is about fair play in the insurance industry. Advocates want to eliminate practices such as refusing to cover people with pre-existing conditions and jacking up premiums if they’re sick. The most controversial proposal is the establishment of a “public option” – a government insurance plan that would compete against private ones.
Delivery and payment reforms. This is about delivering more effective care at a lower cost.
About 20 percent of the 2.5 trillion dollar annual health care price tag does not contribute to better health.
Prevention. This has been long overlooked in America. Spend a few dollars on foot care for a diabetic and you may prevent a foot amputation and thousands of dollars in expenses.Defining the goals is relatively easy to understand. Implementing them is tough and that’s where people are made to feel stupid – partly by special interest groups who intentionally or unintentionally confuse the debate. Drew Altman, Ph. D., the President and CEO of Kaiser Family Foundation, told me there’s “all kinds of spin, mis-statement of fact and plain old mis-truths being bandied about and the debate is getting nastier and nastier.” He added that people are becoming confused and “it’s beginning to make the public more anxious and antsier.”
Half-truths feed on fear. People are afraid of losing or compromising what coverage they already have. They’re afraid of higher taxes and lower quality of care. Who has the time or patience to read the 1,000-page bill proposed by the House of Representatives? So we rely on summaries and are susceptible to all sorts of misrepresentation. And nobody wants a plan with major faults rammed down their throat in the name of political expediency.
Today’s Kaiser Family Foundation report suggests that the tactics of special interest groups are working. Sixty percent of adults surveyed support a public option. But “(w)hen those who initially support the public plan are told that this could give the government an unfair advantage over private companies, overall support drops to 35 percent. Conversely, when opponents are told that public plans would give people more choice or help drive down costs through competition, overall support jumps to roughly seven in ten.”
It’s in the interest of those who oppose health care reform to make us feel that it’s just too hard to understand. I have certainly felt that way at times over the past year. But the stakes are too high for Americans to bale out on the discussion. Our common sense and sense of fair play are crucial to the national conversation. We should hear out the special interest groups; they often have legitimate concerns and thoughtful analysis. But we need to remember where they are coming from. And we must seek out information from sources that try to be nonpartisan, such as the
Kaiser Family Foundation.
No, you’re not stupid if you’re confused about health care reform. But you may be psyched out. You probably know a lot more than you think – but you may need to do some homework in order to participate in this extraordinarily important national debate. The national debate needs you.
For this week’s CBS Doc Dot Com, I moderate a debate about the public option between Wendell Potter, former head of public relations for Cigna and Rob Schlossberg, Executive Sales Director for BenefitMall. Mr. Schlossberg opposes it and Mr. Potter favors it.
To view the debate on a public option, click here.
To view a brief discussion of for-profit vs. not-for-profit health insurance organizations, click here.
For Janet Adamy’s excellent summary, “Ten Questions on the Health-Care Overhaul,” in the July 21st issue of the The Wall Street Journal, click here.
My Interview With President Obama On Health Care Reform
I met President Obama yesterday. I interviewed him at the White House about his proposals for health care reform. But naturally, as we greeted each other, I asked about his throwing out the first ball at the All Star Game the night before.
“Were you nervous about bouncing the ball?” I asked. He grinned. “I will say it’s actually nerve-wracking,” he said. “When they hand you the ball, there are just a lot of things that can go wrong.” I found that to be a perfect metaphor for his assuming the Presidency of the United States and attempting to overhaul the health care system.
The biggest news from yesterday’s interview: President Obama has changed his position from the campaign trail and now believes that health care insurance should be mandated for all Americans, with a hardship exemption.
Dr. LaPook: Ultimately, philosophically, do you believe that each individual American should be required to have health insurance?
President Obama: I have come to that conclusion. During the campaign, I was opposed to this idea because my general attitude was the reason people don’t have health insurance is not because they don’t want it, but because they can’t afford it. And if you make it affordable, then they will come. I’ve been persuaded that there are enough young uninsured people who are cheap to cover, but are opting out. To make sure that those folks are part of the overall pool is the best way to make sure that all of our premiums go down. I am now in favor of some sort of individual mandate as long as there’s a hardship exemption. If somebody truly just can’t afford health insurance even with the subsidies that the government is now providing, we don’t want to double penalize them. We want to phase this in, in a way that we have time to make sure that coverage is actually affordable before we’re saying to people “go out and get it.”
The interview went very smoothly and fairly predictably until we reached the following exchange:
Dr. LaPook: You’ve said that if doctors have the information, they’ll do the right thing. And generally, I like to — I’m a physician and practicing — I think that’s true. But actually, there are a lot of times when that’s not the case. For example, angioplasties — elective angioplasties, where you open up a clogged artery in the heart. It turns out that about 30 percent of them are unnecessary, that they’re done and you try to open up an artery of the heart, but really it’s no better than medication, and doctors know this, but they still order them.
President Obama: Why are they still ordering them, do you think?
I will admit that he took me by surprise by turning the question on me. Suddenly I was not in a one-way interview, I was in a conversation. Politics aside, it was clear to me that he was listening and he was curious.
Dr. LaPook: I think that because they believe — there’s this thing about — if an artery’s closed. It’s got to be better if it’s open, and it turns out that’s not true. So they have on the one side their intuition as a physician, in their bellies, and then there’s the evidence-based medicine that we talk about, and they clash a lot at times, so how do you make that doctor do the right thing or give him the right incentives?
President Obama: I have enormous faith in doctors. I think they always want to do the right thing for patients. But I also think, if we’re honest, doctors, right now, have disincentives to making the better choices in the situations you talked about. If you are getting paid more for the angioplasty, then that subconsciously even might make you think the angioplasty is the better route to take. And so if we’re reimbursing the physician not on the basis of how many procedures you’re performing but rather how are you caring for the patient overall – what are the outcomes – then I think you start seeing some different choices. And at the very least, you’re not taking money out of physicians’ pockets for making the better choice. So it’s a combination of better information and then, I think, a different system of reimbursement that says, “let’s look at the overall quality of the care of the patient.”
My conversation with President Obama illustrates a crucial focus of the current healthcare debate: figuring out if the American people are getting their bang for the buck when doctors order tests, perform procedures, and prescribe medications. The current buzzwords among doctors and politicians are “evidence-based medicine” (is there proof that something works?) and “comparative effectiveness” (if there’s more than one way to do something, what works best?). An Institute of Medicine workshop about evidence-based medicine began today in Washington, with the following listed as “issues prompting the discussion”:
. “Health costs in the United States this year will be about $2.5 trillion—nearly 17% of the economy.
. The United States spends far more on health care than any other nation, 50% more than the 2nd highest spender and about twice as high as the average for other developed countries.
. Overall health outcomes in the United States lag behind those achieved in other countries.
. Consistent with the per capita figures, many researchers studying the nature of U.S. health expenditures feel that 20% of our expenditures do not contribute to better health.”
Expert groups are currently trying to establish guidelines for reimbursing health expenses based on clear results from well-designed clinical studies. The problem is that for many medical issues, there is no definitive, evidence-based approach. Clinical medicine is often based on inexact, immeasurable tools such as intuition and experience. As doctors, we don’t have the luxury of waiting for the twenty-year study to be completed. We have to treat the patient now, as best we can, without perfect information.
In the absence of definitive data, we will need to account for clinical judgment in an overhauled health care system. What will happen when the doctor suggests something the insurance company says is not indicated? Opponents of a public option for insurance warn about the danger of having a bureaucrat in between the patient and the physician. But that threat already exists in the current system every time an insurance company decides whether to approve a claim. Wendell Potter, former head of Public Relations for Cigna, recently told
Bill Moyers about Cigna’s decision to deny a liver transplant to a 17-year-old girl, Nataline Sarkisyan, even though her doctors at UCLA had recommended the procedure.
A public-relations uproar forced Cigna to reverse its decision; the company subsequently explained its reversal as an exception, saying the surgery was approved “despite the lack of medical evidence regarding the effectiveness of such treatment.”
Ms. Sarkisyan died hours after Cigna’s decision, without having received the transplant.
A critical flaw in the current system – and one that must be addressed in any overhaul – is that the same people who refuse to pay for a recommended course of action are the ones who consider the appeal of that decision. And, lo and behold, they usually end up agreeing with themselves! In more than two decades of medical practice, I have spent countless hours trying to get various services covered by payors. One encounter – when I tried unsuccessfully to get a stomach-acid lowering pill approved for a patient who needed it -ended up as an example of twentieth-century frustration in
Letters of the Century.
Yes, our current health care system is not sustainable and we do need an overhaul. But there is no “exactly how” and we cannot afford to wait for one. There are so many nuances to the moving target of health care and so many unknowns that it is impossible to create a perfect solution on paper. I’ll settle for an imperfect solution that addresses the most important problems first and represents the best efforts of our most thoughtful experts. But it should not be set in stone. It must include provisions to mature gracefully into versions 2.0 and beyond.
“It’s my OCD.” I hear that on and off from friends and patients who half-jokingly use the term to describe overly careful behavior (such as double-checking to make sure the stove is off) but don’t actually have obsessive-compulsive disorder. True OCD can be a devastating disease. Patients have intrusive, uncontrollable thoughts and severe anxiety centered around the need to perform repetitive rituals. They can be physical such as hand washing or mental such as counting. The behavior significantly interferes with normal daily activities and persists despite most patients being painfully aware that the obsessions or compulsions are not reasonable.
OCD affects 2-3 percent of the world’s population. We’ve seen characters with the disorder portrayed in television (e.g., Tony Shalhoub’s Adrian Monk) and in film (e.g., Jack Nicholson’s Melvin Udall in “As Good As It Gets.”) Yet it’s still associated with stigma, shame, and an alarming level of ignorance by many health professionals. On average, people look for help for more than nine years and visit three to four doctors before receiving the proper diagnosis. In an excellent review article on the subject, Dr. Michael A. Jenike, offers three helpful screening questions: “Do you have repetitive thoughts that make you anxious and that you cannot get rid of regardless of how hard you try?” “Do you keep things extremely clean or wash your hands frequently?” And “Do you check things to excess?” He suggests that answering “yes” to any of these questions should prompt an evaluation for possible OCD. Of course, these are just screening questions and keeping a spotless kitchen doesn’t mean you have a disorder.
For this week’s CBS Doc Dot Com, I interviewed Jeff Bell, KCBS radio broadcaster and author of Rewind, Replay, Repeat: A Memoir of Obsessive Compulsive Disorder and When In Doubt, Make Belief: Life Lessons from OCD. He poignantly told me about the mental anguish associated with his illness, how it threatened to sabotage his career and personal life. His OCD focused on a fear of unintentionally harming others. He found himself unable to drive a car because every time he hit a bump he was afraid he had run somebody over; each time, he needed to get out and check. Even walking to work presented a challenge. He explained that a twig on the sidewalk could stop him in his tracks and fill him with what he knew were irrational thoughts but was powerless to control. Maybe somebody would be harmed by the twig if he didn’t move it. But if he did move it then maybe somebody would be harmed who wouldn’t have if he had just left it alone.
Jeff Bell sought treatment and turned his life around. His message is that others can do the same. Highly successful approaches including cognitive-behavioral therapies and medication can help the majority of patients. But only those who ask for help.
Resources for OCD include: The Obsessive Compulsive Foundation, The Association for Behavioral and Cognitive Therapies, and The New England Journal of Medicine.
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