May 25th, 2009 by EvanFalchukJD in Better Health Network
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Writing about health care reform, Peggy Noonan complains of the decay of the English language:
A reporter asked a few clear and direct questions: What is President Obama’s health plan, how would it work, what would it look like? I leaned forward. Finally I would understand. [Secretary of Health and Human Services Kathleen] Sebelius began to answer in that dead and deadening governmental language that does not reveal or clarify, but instead wraps legitimate queries in clouds of words and sends them our way. I think I heard “accessing affordable quality health care,” “single payer plan vis-a-vis private multiparty insurers” and “key component of quality improvement.” . . . . As she spoke, I attempted a sort of simultaneous translation. . . . But I gave up. Then a thought crossed my mind: Maybe we’re supposed to give up! Maybe we’re supposed to be struck dumb, hypnotized by words and phrases that are aimed not at making things clearer but making them obscure and impenetrable. Maybe we’re not supposed to understand.
Noonan is on to something, but it’s not what she thinks. What she’s hearing is real-life language of our health care system from the people in charge of it. And it’s not just government officials who talk this way — Sebelius’ language is just as common in the private sector.
It reveals the deepening divide between how people talk about health care and what it really means to be sick. Noonan jokes that if Sebelius’ child were to get a high fever she might say “This unsustainable increase in body temperature requires immediate access to a local quality health-care facility,” instead of just “We have to go to the hospital.” But I don’t believe that.
When a loved one is sick, all the abstract ideas melt away. It becomes about trying to get help from a doctor, and a doctor doing his or her best to help.
You might think our health care system would be set up to make that process easier. But it isn’t.
Patients and doctors report in overwhelming numbers how dissatisfied they are with what they see as the interference of well-meaning insurers, governments and others.
You might also think that the reform conversation happening in Washington would have the doctor-patient relationship at the forefront. But it doesn’t.
Look at the “eight principles of health care reform,” proposed by the President and supported by the big players in health care:
(1) protecting families’ financial health, (2) making health coverage affordable, (3) aiming for universality, (4) providing portable coverage, (5) guaranteeing choice, (6) investing in prevention and wellness, (7) improving patient safety and quality, and (8) maintaining long-term fiscal sustainability.
What does all of this stuff mean? How do you talk about health care and not even use the word “doctor” or talk about “patients”? Worse, I’m not sure more than one or two of these even qualify as “principles” as that word is normally used. So what’s going on?
I don’t think anyone is trying to deceive anyone. Like Sebelius’ choice of words, the list is as much of a description of the problem as a solution to it. We don’t have a consensus of what is really important in health care, so we avoid the problem altogether by using vague language that everyone can support. What’s worrisome is that vague, abstract talk is almost certain to lead to vague, abstract solutions.
Before we try to reform health care, let’s first talk about it in plain, clear language.
*This blog post was originally published at See First Blog*
May 15th, 2009 by DrRich in Health Policy
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DrRich’s valued colleague R. W. Donnell, who writes Notes From Dr. RW, has responded to a recent post in which DrRich bravely came out in favor of Comparative Effectiveness Research, even at the cost (DrRich asserted) of alienating the majority of the more conservative-leaning components of his readership.
Dr. RW, noting DrRich’s claim that conservatives have laid out a formal policy of opposition to CER, says:
“OK, stop. Where are these people, conservatives or those of any ilk, who have taken a position against CER? Dr. Rich cites groups who are skeptical and very concerned about the new political agenda for CER, not CER itself.”
Dr. RW is, of course, correct. Research that compares the relative effectiveness of medical procedures or treatments is not only inherently a very good thing, but also is a form of research that has a long and proud history. Healthcare would be an even more dire activity than it is today without the large body of research that guides physicians in making recommendations to their patients when more than one option is available. So yes, comparative effectiveness research is obviously a valuable and time-honored endeavor, and for anyone (conservatives or anyone else) to come out against it would be akin to coming out against babies, or bunnies. (Though, as one whose effort to grow vegetables has been severely challenged each year by a pride of aggressive rabbits, DrRich, as it happens, is indeed against bunnies.)
So, to reiterate, neither conservatives nor anyone else are really against comparative effectiveness research, just as Dr. RW asserts.
What they are against is Comparative Effectiveness Research. They are against a new government bureaucracy that sets the CER agenda, whose stated goal is to create a more efficient and less expensive healthcare system, and that will have the authority to determine what gets reimbursed and what doesn’t.
Dr. RW has made it plain that he is not confused about the following point, but many are: There is a difference between comparative effectiveness research (whose unambiguous goal is to compare the clinical effectiveness among different treatment options, so as to offer physicians objective guidance in making clinical decisions, and which is as unassailable as babies and bunnies), and Comparative Effectiveness Research (which is to be operated by a new government bureaucracy, whose agenda regarding what kind of effectiveness is actually to be compared is intentionally ambiguous).
The ambiguity of CER (as compared to cer) was made clear recently when Peter Orszag testified on behalf of the administration before the Senate Finance Committee. When queried by skeptical Republicans on the ultimate goal of the proposed CER board, Mr. Orszag was evasive. Specifically, when asked by Senator Kyle (R-Arizona) whether the CER board would be empowered to make decisions on which medical services will be reimbursed, Mr. Orszag finally replied, “Not at this point,” a reply which did not alleviate the suspicions of the minority party.
To state the ambiguity more plainly, it is clear that while the CER board will mainly be concerned about comparing “cost effectiveness” (which is the only way they can potentially achieve their main goal of reducing healthcare costs), the only kind of effectiveness they are willing to discuss publicly is “clinical effectiveness.”
This studied ambiguity allows proponents of the new government plan to paint opponents of the CER board as being against the “babies and bunnies” form of comparative effectiveness research, and thus reveal those nay-sayers as being beneath contempt, unworthy of anyone’s attention. Meanwhile they will be free to advance their real “cost effectiveness” agenda.
DrRich agrees with conservatives that this kind of deceptive ambiguity is indeed contemptible. But really, it is no more contemptible than the thousands of other forms of covert healthcare rationing we see all around us. (Covert rationing inherently relies on ambiguity – saying we’re doing one thing while all the time we’re doing another.)
Having tried to clarify this distinction between cer and CER, DrRich will now repeat that his prior post was not merely to express support for the “babies and bunnies” variety. As Dr. RW points out, everybody is in favor of that kind of comparative effectiveness research.
Rather – and this is where he further jeopardizes his continued tolerance by his conservative readers – DrRich is offering his support to the other kind of CER, the kind described in the stimulus bill, which (though the administration will not say it publicly) will undoubtedly use comparative effectiveness research to perform cost effectiveness calculations, then coerce physicians, through one form of federal subterfuge and intimidation or another, to employ the least expensive therapies. The government bureaucrats, just as they are doing today but with less muscle, will shout “quality” while enforcing “cost.”
DrRich supports this kind of CER not because it is a good thing – it decidedly is not. He supports it because here is a form of covert rationing that will at last effect everyone, and will be so blatant that after a time even us Americans will no longer be able to ignore it, try as we might. DrRich believes that relatively soon, we would notice that here is a cadre of unelected bureaucrats rationing our healthcare – determining which of us lives and dies – through some opaque process, and lying to us about it the whole time. He believes this to be the pathway most likely to get the American people to finally face the fact of healthcare rationing, and to goad them into an open debate on the best and least harmful way to accomplish it.
Go ahead. Call him a cock-eyed optimist.
*This blog post was originally published at The Covert Rationing Blog*
May 11th, 2009 by EvanFalchukJD in Better Health Network
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The New York Times interviews President Obama about health care:
I’m a pretty well-educated layperson when it comes to medical care; I know how to ask good questions of my doctor. But ultimately he is the guy with the medical degree. So, if he tells me, You know what, you’ve got such-and-such, I don’t go around arguing with him or go online to see if I can find a better opinion than his.
It’s shockingly bad advice.
Numerous studies show that patients get the wrong diagnosis as much as 20% of the time, and get the wrong treatment half of the time. Thirty-five percent of doctors and 42% of patients report errors in their own care or that of a family member. Studies show that most errors happen because of a failure to analyze the patient’s problem correctly. Experts, like Dr. Jerome Groopman from Harvard, say that doctors, strapped for time and dealing with complicated problems, easily fall prey to cognitive pitfalls that create poor quality.
Ask questions, be skeptical, disrupt your doctor’s thought process. Make sure the decisions about your care are right.
Above all, remember it is you, the patient, that are in charge, not the “guy with the medical degree.”
(h/t @epatientDave via twitter)
*This blog post was originally published at See First Blog*
May 11th, 2009 by KevinMD in Better Health Network
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One question that occasionally comes up is whether doctors should be paid a flat salary or not.
Currently, the majority of physicians are paid fee-for-service, meaning that the more procedures or office visits they do, the better they are reimbursed. This, of course, gives a financial incentive to do more, without regard to quality or patient outcomes.
One proposed solution is simply to pay doctors a flat salary, with bonuses for better patient outcomes.
Well, according to a recent Kaiser/NPR poll, that idea is a no-go for patients. 70 percent of patients think its better that a “doctor gets paid each time they see you,” while only 25 percent think a yearly salary is better.
As an aside, I find it interesting that any public poll result that goes against the progressive health policy agenda is considered a “weak opinion,” but really, this isn’t a surprising result.
Economist Uwe Reinhardt hinted at the cause when he said that most Americans believe “that they have a perfect right to highly expensive, critically needed health care, even when they cannot pay for it.”
Perhaps the public believes that a salary is similar to the capitation debacle in the 1990s, where doctors were paid a fixed fee, which gave them an incentive to deny care. And any perceived attempt to restrict care will be met with visceral opposition by the American public.
Which again shows how difficult it will be to engage patients with any dialogue that involves cost control.
*This blog post was originally published at KevinMD.com - Medical Weblog*
April 5th, 2009 by eDocAmerica in Better Health Network
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“Internet 2.0” emphasizes social networking over simply downloading and reading “content”. The world of Twitter, blogging, facebook, e mail, and text messaging is revolutioning our society and rapidly becoming a major force in the way we work and play. It remains to be seen, however, how it will impact health care. There are many, many issues that are no where near resolution.
Although, at eDoc, we have been involved in online health for over a decade, we still run up against innumerable barriers and resistance factors that prevent this modality from truly becoming mainstream.
In order for this to occur, I believe the following needs to happen:
1. The team providing the service must be of high quality. This is difficult to determine in the best of circumstances and almost impossible in the often murky, even sleazy, world of internet
2.0. Until there is a better system for this, the user must be careful to scrutinize the credentials of the professionals involved and understand the business model behind the product. Check to make sure that the physicians are board certified. Beware of industry supported sites that are, essentially, using their web site to sell another product and “giving away” medical content or advice. If possible, find someone else who has used the service and ask whether the service is reputable. If you decide to try the service, dip your foot in the water and assess the quality of what you get back. If you like what you get, try again. If not, run in the other direction!
2. There has to be a widely available method for professional reimbursement. At eDoc, we developed a business model in which sponsoring corporations purchase the service on behalf of their employees or members. Most insurance companies do not cover on line visits with a physician but this is likely to be the case in the future; and, until that occurs, most docs won’t or can’t afford to, get on line to provide feedback or information to their patients.
3. Better tools are needeed. Although there are a lot of good web sites with good medical content, web tools are just starting to be designed to take advantage of the Web 2.0 world. Good, user-friendly, secure patient and provider portals will need to be connected to eprescribing hubs, will need to readily switch to search for internet sites to attach, will need to accept and view video footage, will need capability to connect through digital cameras for real time viewing and communication, and need easy to use, menu driven drop downs that guide the patient and provider through an online encounter.
For now, eDoc has a high quality team that uses a free form communication model and offers medical, dental, pharmaceutical and mental health professional advice. We are watching with eager anticipation to see what the future brings and, hopefully, we can stay ahead of the curve and continue to offer the highest quality online heath professional experience.
Your comments and dissenting opinions are welcome…
**This blog post was originally published by Dr. Charlie Smith at eDocAmerica’s blog**
