Tuesday, September 29, 2009

Is it morally objectionable for physicians to consider cost in treatment decisions?

Yes, according to a majority of physicians in a recent poll. The survey, which was reported in the September 14 edition of the New England Journal of Medicine, found that 54% of surveyed physicians said that they had "moderate" (40%) to "strong" (14%) moral objections to using cost-effectiveness data to determine which treatments to offer to patients. 45% said they had no such moral objections.

A third of physicians had moderate to strong disagreement with limiting reimbursement for high cost procedures or drugs in order to help expand access to basic coverage to those who do not have it, while 67% favored such limitations to expand access for others. Primary care physicians were more likely than surgeons or procedural specialists to support limits on payments to help fund basic care for others.

The survey has some other surprising findings. While a large majority of physicians agreed that physicians are ethically obligated to care for the uninsured and underinsured, 27% moderately or strongly disagreed. Slightly more than one out of five physicians agreed that addressing societal health policy issues, as important as that might be, falls outside their professional obligations as physicians.

Like any poll, how a question is worded can produce a quite different result. I wonder, for instance, if fewer physicians would have moral objections to cost-effectiveness data if it was to "guide" or "inform" patient care decisions rather than "determine which treatments will be offered to patients" as stated in the survey. I can see why the notion that a treatment might not be even offered to patients, if it was determined not to be cost-effective, would raise moral objections. Comparative effectiveness research, at least the way ACP has envisioned it, should be used to engage patients in shared decision-making with their physicians on which course of treatment might work best for them, not to deny them this choice by taking the more expensive treatments off the table.

At the same time, the survey suggest to me that many physicians do not agree with concepts of social justice and fair allocation of resources as described the Physician's Charter on Professionalism, which has been endorsed by the ACP, the American Medical Association, the American Board of Internal Medicine, among others. The Charter's principle of social justice states that "The medical profession must promote justice in the health care system, including the fair distribution of health care resources." It also states that physicians must have a commitment to a just distribution of finite resources:

"While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician's professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one's patients to avoidable harm and expense but also diminishes the resources available for others."

Today's questions: Do you personally have a moral objection to using cost-effectiveness data to determine the treatments offered to patients? What about to guide and inform such treatments? Do you agree or disagree with the Charter's view that physicians must be committed to social justice and a fair distribution of finite resources?

Thursday, September 24, 2009

"You can't always get what you want . . .

. . .But if you try sometimes, well you might find,
You get what you need."

So sings Mick Jagger in this rousing refrain from the hit song on the Rolling Stone's 1969 "Let it Bleed" album.

Most people wouldn't look to Mick Jagger and Keith Richards as a source of child-raising advice. But I have quoted this phrase many, many times to my kids. Like when my 17 year old daughter recently insisted that she needed a "cool" new cell phone, when she already had a perfectly good phone. Of course, telling her that "you can't always get what you want" didn't help my approval rating that night.

The advocates of health care reform are dealing with something similar. What people want is unlimited health care, paid for by someone else, at no cost to them. What they need is access to care that is reasonably affordable, with some limits to ensure that the total price tag doesn't bankrupt the country.

It is the "limits" part that has people upset. They instinctively understand that health care reform will involve some limits on their own care, even as heath reform advocates try to sugar-coat things by saying it can all be paid for by reducing waste and fraud and promoting "value" and "efficiency" in health care. We can deny all we want that health care reform will lead to rationing, yet much of the public believes that in the end, the government will put limits on the care they want.

I think this explains the ambivalence about health reform in recent polls. The Kaiser Family Foundation's August tracking poll found that 45% of voters felt that health care reform would make "the country as a whole" better off but only 36% felt it would do the same about them and their families. Only 29% thought it would make the quality of care better for them personally, but 37% thought it would make quality "in America" better. 42% thought that it would make wait times for non-emergency treatments personally worse for them. 51% were more worried that Congress would pass a bill that won't be good for them and their family, compared to the 39% that were more worried that Congress wouldn't pass a health care reform bill this year.

The public's concern about the impact of health care reform on them personally is appropriate and understandable. President Obama has tried to blunt this by emphasizing how people with health insurance will benefit from reform, and some other recent polls suggest that he is making progress.

I think the President has not squared with the American people that it isn't possible for everyone to get everything they want. But the critics of his efforts have also done a disservice by screaming "rationing" every time the discussion turns to controlling costs.

The issue, in my mind, is not whether there will be limits - call it rationing if you must, although it is such a loaded term. Instead, the question is who will do the rationing and how. Should we continue to leave it to insurance companies to limit services by denying coverage for people with pre-existing conditions, cancelling coverage when they get ill, and finding every possible reason to deny claims for services?

Should we do it based on who has access to health insurance and who doesn't? By how rich your benefits package is? By whether you work for an employer who can provide coverage, or whether you work for a small company that cannot? By giving everyone a high deductible plan so they are more responsible for the cost of their own care? By making smokers and others who have so-called "lifestyle" illnesses pay more? By having the government fund research on the clinical effectiveness of different treatments and then designing benefits, coverage, and payment policies around such research?

Good arguments can be made for, and against, almost all of these approaches, but at least they recognize the simple fact that when it comes to health care, you can't always get what you want, but if you try sometimes, well you might find, you get what you need.

Today's question: Do you think it is possible to engage the public in a rational discussion about rationing?

Tuesday, September 22, 2009

Let the sausage-making commence!

Senator Max Baucus today released a revised draft of his health reform bill, which will be marked up (amended) by his Senate Finance Committee beginning today. As many as 600 amendments have been drafted. The amendments generally fall into the following categories:

1. Amendments by Republicans who will not vote for the bill, no matter what, and that have little possibility of being accepted by the committee. Most of the GOP amendments would eliminate the cost controls in the bill (striking Baucus' proposals to create a Medicare advisory commission, or fund comparative effectiveness research, for instance), eliminate mandates on individuals and employers, strike proposed cuts in payments to providers, and eliminate any and all tax increases to fund coverage expansions.

2. Amendments by liberal Democrats to replace the bill's health plan co-operatives with a strong public plan option.

3. Amendments by Democrats to increase the subsidies so as to make coverage more affordable when an individual mandate takes effect. Olympia Snowe (R-ME), the one Republican who seems open to voting for the bill, also supports increasing the subsidies.

4. Amendments offered by Republicans and Democrats alike to promote specific policies they favor. For instance, a number of amendments were offered to increase support for primary care training programs.

My favorite amendment, apparently offered tongue-in-cheek by Senator Orrin Hatch (R-UT), would exempt any state beginning with the letter "U" from the excise tax on high cost insurance plans.

The overall direction of the revisions made today by Senator Baucus, and the amendments most likely to pass, will be to broaden federal assistance to those who need help buying coverage (which will drive up the cost of the bill) while at the same time reducing the tax increases and budget offsets (cuts) that he hopes to use to pay for the legislation. The risk is that this will end up increasing the price tag to the point that it will test his, and the Senate's, commitment to passing a bill that won't add to the deficit.

ACP, for its part, sent a letter to Senator Baucus with our views on what we like and don't like about his proposal.

The legislative process is not for the faint of heart. It is messy and contentious and sometimes produces an unpalatable product that no one will swallow. Other times, though, it produces something worthy of consumption - just like the sausage-makers to which Congress is often compared. We'll see soon which will be the case this time around.

Today's question: How many states begin with the letter U? Or, more seriously, what do you expect this process to produce?

Monday, September 21, 2009

A Tale of Two Presidents

The media is abuzz about President Obama's "unprecedented" presence yesterday on five network and cable interviews to make his case for health reform, to be followed tonight with an interview on the David Letterman show. As President Obama continues to make his case to the American people, might I be so bold as to suggest that he take note of an op-ed that appears today in the Atlanta Journal Constitution, written by ACP's own President, Joe Stubbs, MD? I am biased, but I think Joe makes as good a case as anyone, on why reform is imperative. He writes:

"I take care of patients in a general internal medicine practice in Albany, as I have done for the past 27 years. I take enormous professional pride and satisfaction in keeping my patients healthy, helping to heal them and providing comfort and relief when they are nearing the end of their life. I also share their frustrations with a health care system that is stacked against us both; a system that is unacceptable and unsustainable. Examples readily come to mind to support this point. By 2017, an average middle-income family will spend $4 out of every $10 they earn on health care alone, putting it out of reach for most. Just three years later, the number of uninsured is expected to climb from today's 46 million to 60 million, which is about one in five of our population. And, those with insurance will not be able to find a primary care doctor because of a growing primary care physician shortage of tens of thousands ...

Within our grasp is the achievement of health reform legislation that makes coverage affordable by building upon and improving our current employer-based system, providing incentives for young doctors to go into primary care, reforming and improving Medicare physician payments, and reducing the costs associated with our broken medical liability system. Let's not let the opportunity slip away."

If Joe is right that rising costs will exceed the ability of families to afford coverage - and I have no doubt that he is - then why does the public not seem to have the same sense of urgency? Ezra Klein writes in yesterday's Washington Post that the cost of health care to individuals and families is masked by the fact that employers pick up (most) of the tab. But when employers pay more for health care, they pay their employees less in wages. Health care costs arguably may be the biggest cause of decades of wage stagnation for middle and lower class families.

The political dilemma is that since the public doesn't readily see the impact of rising health care costs on their livelihood - unless they are among the unfortunate millions who have no health insurance coverage or have experienced personal bankruptcy because of a personal health care catastrophe - they don't want to hear about the need to control costs. When even relatively mild ideas to control costs are proposed - like funding research on the comparative effectiveness of different treatments, or reimbursing doctors and patients to sit down together to discuss advance directives - they are demagogued as "rationing" by some politicians.

This is why the political debate is shifting to things that are relatively popular with the public - like prohibiting insurers from turning them down if they have a pre-existing condition or cancelling their insurance if they get sick - instead of controlling costs. The idea seems to be to sell the public on the gain from insurance that can't be taken away, while postponing a discussion of the pain involved in controlling costs. Even though, as Joe Stubbs wrote, the cost of the current system is not sustainable for his patients and their families.

Today's questions: What do you think of the views expressed by Dr. Stubbs? How would you recommend engaging the public in a discussion of the cost of health care?

Wednesday, September 16, 2009

Baucus offers plan to extend coverage, cut deficit, and increase primary care fees

Today, Senator Max Baucus (D-MT), chair of the Senate Finance Committee, released his version of health reform. ACP is analyzing the bill, so I'll have more to say about it in subsequent blogs. A few highlights, or lowlights, depending on your point of view:

The CBO projects that the bill will reduce the deficit by $49 billion over ten years, and that likely it would to continue to reduce the deficit in subsequent years.

It is financed principally by a tax on insurers who sell high cost health plans and by savings in Medicare and Medicaid. There is no direct tax increase on higher income persons, as in the House bill, although the insurance tax on high cost health plans likely would be passed onto to people enrolled in such plans.

The bill bans most insurers from excluding or cancelling insurance based on a person's health status or pre-existing condition, and limits the factors that can be used in setting premiums.

It provides subsidies for people up to 400% of the federal poverty level to buy coverage through an exchange (purchasing pool), but the subsidies are much lower than in the House bill. With the result that out of pocket costs will be much higher, especially for younger persons.

Individuals seeking subsidies or coverage through an alliance would have to submit documentation that they are in the United States lawfully.

The bill provides additional funding for states to expand Medicaid to 133% of the federal poverty level.

It does not include an employer mandate. Instead, large employers who do not cover their workers will be required to pay the costs of any federal subsidies extended to those workers.

No public option; instead, regional non-profit cooperatives are proposed to compete with private insurers.

Everyone, with only a few hardship exceptions, would be required to buy coverage.

On physician payment, it would provide only one year of relief from the Medicare SGR physician pay cuts (0.5% increase instead of a 21% cut in 2010), paid for in a way that will cause an even bigger cut the following years. Congress would then need to pass legislation next year to halt the subsequent years' cuts, at an even bigger budget price tag.

Senator Baucus proposes to give general internists, family physicians, pediatricians, and geriatricians a 10% bonus payment for designated office visits and other evaluation and management services. Half of this would be paid for with additional federal spending, the remaining by a small (half percent) across-the-board reduction in Medicare physician fee schedule payments. The House version, H.R. 3200, proposed a 5% primary care bonus paid for entirely with new federal dollars (no budget neutrality offset to other physician services).

Oh, and despite months of working to get GOP support, Chairman Baucus had to admit that as of now, not a single Republican has signed onto the bill, although he expressed confidence (hope?) that he'd have some level of bipartisan support by the time that the Senate Finance Committee takes up the bill next week.

I expect that ACP will find some things we like in the Baucus bill, but other things - especially the fact that it just kicks a solution to the Medicare SGR pay cuts down the road - are likely to be of real concern. I am interested though in readers' initial reaction to the proposal, and especially to the idea of giving primary care physicians a bigger raise, paid for in part by a modest reduction to other physicians.

Today's questions: What is your initial reaction to the Baucus plan? Is it reasonable to ask all physicians to chip in a half percent of their Medicare fees to help fund a 10% increase in designated services by primary care physicians?

Tuesday, September 15, 2009

New poll shows physician support for expanded government role in coverage

I have received quite a few comments from ACP members who say that the College's positions on health reform are not representative of most internists' views. For instance, on Friday an internist posted the following comment in response to my blog about Obama's speech to Congress:

"You will be hard-pressed to find a physician outside of a university setting that supports this ridiculous bill . . ."

Lately, such criticisms have come mostly from the right of the political spectrum. Over the years, though, I have heard from many ACP members who support a single payer system; they also claim most internists agree with them and that ACP is out-of-step with its membership.

A new poll, funded by the non-partisan Robert Wood Johnson Foundation, found that a large majority of physicians - almost 63% - "support proposals to expand health care coverage that include both public and private insurance options - where people under the age of 65 would have the choice of enrolling in a new public health insurance plan (like Medicare) or in private plans government." Fewer than one in ten of the physicians surveyed support a single government plan (Medicare for all) that replaces private insurance. Large majorities of physicians also support a Medicare buy-in option for people between the ages of 55 and 65. Primary care physicians - internists, pediatricians, and family physicians - were the most supportive of providing a public and private option, with 65.2% being in favor.

Physicians in all regions of the country supported a public-private option, with support ranging from a low of 58.9% in the south to a high of 69.7% in the northeast. 63.3% of physicians in urban areas and 59.6% in rural ones supported the public-private option. It wasn't just academic or salaried doctors who said they support a public plan option. Solid levels of support were found from physicians in private practices (59.7%), those who are involved in patient care more than 20 hours per week (62%), and those who get most of their income from direct billing rather than salary (58.9%). More than six out of ten AMA members expressed support for a public-private option.

Now, I have learned from experience that people tend to dismiss as being "biased" polls that do not agree with their own views. I also recognize that polls have their limitations, and some are more accurate than others. Some polls, especially those funded by advocacy organizations or political parties, should rightly be suspected of carrying bias. But there are a lot of highly respected researchers who are doing their best to capture accurate information about physicians' and the public's views, and I think this polls meets any reasonable standard of credibility.

Polls are snapshots of opinion, and opinions can change rapidly as circumstances change. Plus, complex issues like health reform aren't easily captured in a single poll. This poll did not ask the physicians about their specific views on President Obama's plan or the bills pending in Congress. Nor did it ask their views on financing health reform through higher taxes, or requiring that individuals buy insurance. Still, the poll suggests that there is broad and deep physician support for a larger federal government role in health care.

Now, just because physicians seem to agree on the need to provide the public with a choice of public and private plans doesn't make it the right policy prescription for America. A principled argument can be made against giving the government a bigger role in health care, just as a principled argument can be made for a single payer system. Still, physicians making such arguments should be aware that they seem to be at odds with where most of their colleagues stand.

Today's question: Do you agree with the poll's finding that most physicians support giving people the option of enrolling in a Medicare type program, along with private insurance? If you don't agree, are there alternative surveys or data on physicians' opinions that this blog's readers should know about?

Monday, September 14, 2009

Internists and the pursuit of happiness

Internal medicine physicians, it is often suggested, are a pretty unhappy bunch. They are overworked and underpaid. They spend too much time on paperwork and too little time on patient care. Older internists, who remember the good old days, are less happy than younger ones. Rising costs and low fees have caused most to close their practices to new Medicare patients. General internists are more dissatisfied than subspecialists.

Most of these assumptions are based on anecdotal information, but what do we really know about how internists view their careers and their profession? A new survey of over 4,500 physicians, conducted by the well-respected Center for Studying Health System Change (CSHSC), suggests that the state of internal medicine is more nuanced than the popular portrait of disgruntled practitioners looking for an exit sign. (See Wall Street Journal writer, Jacob Goldstein's, take on the new survey.)

The CSHSC found that more than three out of four internists (76.4%) are "very or somewhat satisfied" with their careers; 5.4% are neither satisfied nor dissatisfied, 14.1% are "somewhat dissatisfied"and 4.1% are "very dissatisfied". Still, a smaller proportion of internists reported that they are more satisfied than any of the other surveyed specialties. 80.3 percent of family physicians, 83.4% of medical specialists, 80.5% of psychiatrists, 81.5% of surgical specialists, 80.5% of ob/gyn physicians, and a whopping 88% of pediatricians said that they were very or somewhat satisfied. Surgical specialists reported the highest proportion (4.7%) of physicians who said they were very dissatisfied.

The survey also shows that money doesn't necessarily buy you love (of career). Among all physicians, physicians who make more than $250,000 annually reported higher levels of satisfaction (86.7%) than those who make between $150,000 and $250,000 (81.8%) and those who earn less than $150,000 (76.8% very or somewhat satisfied). Yet money isn't everything, given that more than three quarters of the lowest earners expressed satisfaction with their careers. More pediatricians say they like their careers than any other physician specialty, even though the Medical Group Management Association reports that pediatricians are second from the bottom in annual physician income. And 11% of the highest earners expressed career dissatisfaction in the CSHSC survey.

Size matters, but also not as much as you might think. More than 82% of physicians in groups of three or more are satisfied with their careers compared to 77% in solo or two physician practices. (There wasn't much difference in satisfaction based on practice size beyond three physicians.) The length of time in practice also is not a clear indicator of satisfaction: "physicians in practice for more than 20 years provided more extreme responses: they were more likely to be either very satisfied or very dissatisfied relative to newer doctors."

What about the idea that most internists have closed their doors to new Medicare patients? 54.7% of internists said they accept all, another 18.6% said they accept most, and 17.2% said they accept some new Medicare patients. Only 9.5% of internists reported that they will not see any new Medicare patients.

The CSHSC survey provides important baseline data for policymakers and the profession on what can be done to make internal medicine a more attractive career path. A glass-half-filled person would say that the good news is that most internists are satisfied, while a glass-half-empty person would point out that internists are less happy than other doctors. The nuanced responses to the survey suggest that getting to the bottom of internists' varying degrees of career (dis)satisfaction is going to more complicated than, say, just increasing pay or getting them to go into larger groups. Money and size matters, but not as much as one might have expected.

Today's questions: How would you interpret the CSHSC data and how it might inform policy decisions on making internal medicine more attractive? How does it square with your own experiences?

Thursday, September 10, 2009

Obama tells the public what "ObamaCare" really means

Even before President Obama uttered the closing words in his health care reform speech to Congress, pundits and politicians alike were tweeting their instant reaction. I am skeptical that hasty opinions can provide an accurate assessment of the impact of the speech on the course of health care reform. This is not to say that the speech didn't have an impact, it is just that we really won't know what the impact is until we see how the public responds over the next days and weeks, and what the politicians do as they figure out how to translate the vision of reform articulated by the president into legislation that can actually pass. Legislation is a slog, and a presidential address - even one as important as this one, delivered at a critical time by a president who demonstrated again his mastery of rhetorical tools of his office - cannot substitute for the nitty-gritting work of finding the legislative "sweet spot" that will unite a fractious Democratic party and deeply divided electorate.

Having just cautioned you about the instant analysis, I am now going to disregard my own advice and provide you my own analysis and what the president's speech might accomplish. Borrowing a phrase from Winston Churchill, though, I also reserve the right to explain afterwards why it didn't happen! (Churchill reportedly once said that, "A politician needs the ability to foretell what is going to happen tomorrow, next week, next month, and next year. And to have the ability afterwards to explain why it didn't happen.")

I think the president's speech potentially accomplished several important things.

First, the president finally answered the call to put his own stamp on health care reform, in much greater specificity than in the past. For all of the talk about "Obamacare" (the catch-all label for critics of the president's efforts), we have not, until now, had a clear idea about what the president really wants. Last night, he made it clear that health care reform, at its most basic level, must regulate the practices of health insurers so that no one can be turned down, have their coverage cancelled, or charged excessive rates because they have a pre-existing condition or health problem. He also said he does not want to put health insurers out of business. He laid out a strong argument for a public plan option as one important piece of comprehensive health reform, but also made it clear that he does not share the views of those on the left or the right who have assigned the public plan with more importance than he thinks it merits. He will fight for a public plan, but only to a point - if he can get what he wants in terms of regulating health insurers and subsidizing coverage, he will not insist that a public plan be included.

Second, he spoke to the need for responsibility for funding health care to be a shared responsibility. The government must provide help to those who can't afford coverage. Employers must provide coverage or pay into a fund to subsidize coverage for their employees. Individuals must buy coverage, with hardship exemptions who still find the cost out of reach.

Third, he forcefully went after critics who have used distortions - he called them lies - to stoke opposition to his proposal. I don't believe that this will stop his critics from doing so, or cause the people who really believe that the president wants to allow government bureaucrats to pull the plug on grandma to change their minds. But his words suggest that there may now be a bigger political cost for doing so. (ACP, for its part, is trying to set the record straight.)

Fourth, he insisted that the legislation will be fully paid for, not adding a "dime" to the deficit. This will create enormous pressure on Congress to either find more savings or scale back the subsidies, but any substantial reduction in the subsidies would go in the face of the president's promise to make coverage affordable to all. I believe that the president missed an opportunity to really be direct with the American people on the sacrifices that real cost control will involve. Instead, he fell on the old argument that most of reform can be paid for by eliminating fraud and waste.

Fifth, he addressed the need for malpractice reform to reduce the costs of defensive medicine. He didn't provide any specifics, other than that he's instructed HHS Secretary Kathleen Sebelius to "immediately" develop a program to provide funding to states to launch demonstration projects to medical liability reform. I don't expect the reforms will include caps on damages. Still, it is an opening on an issue that previously had been ignored by the president and his Democratic allies in Congress.

All of these details were important, but I think the biggest impact of the president's speech may have been in his closing remarks, when he defined health care reform as an issue that will test the moral character of the American people. Referring to the life work of the late Ted Kennedy, Obama said this: "That large-heartedness -- that concern and regard for the plight of others -- is not a partisan feeling. It's not a Republican or a Democratic feeling. It, too, is part of the American character -- our ability to stand in other people's shoes; a recognition that we are all in this together, and when fortune turns against one of us, others are there to lend a helping hand; a belief that in this country, hard work and responsibility should be rewarded by some measure of security and fair play; and an acknowledgment that sometimes government has to step in to help deliver on that promise."

The next few weeks will tell us if he is right in his assessment of the character of the American people.

Today's question: What did you think of the president's speech?

Wednesday, September 9, 2009

Will Health Care Reform Restrain Rising Costs of Health Care Technology?

Advocate Blog Guest Blogger: Jack Ginsburg, Director of Policy Analysis and Research

There is much talk these days of bending the curve of rising health care costs. At least half of the growth in medical spending in recent years, according to an analysis by the Kaiser Family Foundation, is attributable to technological change. Others attribute as much as 75% of the increase to technology. The Congressional Budget Office concluded that, "The general consensus among health economists is that the large increase in health care spending over the past several decades was principally the result of the emergence of new medical technologies and services and their adoption and widespread diffusion by the U.S. health care system."

The use of advanced medical imaging such as CT scans, MRIs and PET scans has soared and accounts for much of the increased cost. Imaging technology has been widely dispersed to outpatient centers and physician practices. But greater availability of technology is associated with greater utilization and higher spending. Consequently, Medicare payments for imaging services grew more rapidly than any other type of physician service between 2000 and 2005. Medicare claims for CT scans more than doubled from 1995 to 2005, and claims for MRI procedures more than tripled. Each additional CT unit in a physician's practice has been estimated to add $685,000 in Medicare spending per year, and each MRI unit costs Medicare $550,000 each year.

Unlike consumer products, like personal computers and flat screen TVs for which prices have declined as supply increased, prices of health care services involving expensive technological equipment generally remain high even after use becomes widespread. Costlier new technologies also tend to replace older, less expensive ones. Prices in Europe and Canada for many of the same technological services are far less and utilization is less, but clinical outcomes are similar or better. This is largely because other countries generally are slower to adopt new health care technology and most have more regulated systems that control the use, availability, and prices of health care services.

The United States lacks a coordinated policy on health technology assessment and has little regulation of the diffusion of technology. The economic stimulus package enacted earlier this year provides increased funding for comparative effectiveness research by the Agency for Research and Quality. Further provisions for development and use of comparative effectiveness research also are contained in some of the proposals for health care reform. Current proposals will stimulate research to generate information on relative effectiveness, but how that information will be used is not specified. Hopefully, physicians and patients will use the information in making evidence-based treatment decisions that will reduce inappropriate utilization. However, some fear that insurers and government will use comparative effectiveness data to restrict insurance coverage and deny claims.

In a position paper just published by ACP, the College recommends that a coordinated, independent, and evidence-based assessment process should be created to analyze the costs and clinical benefits of new medical technology. ACP advises that coverage and payment policies of public and private health benefit plans should be based on evidence of clinical and cost effectiveness. ACP maintains that information about the effectiveness and outcomes of technology should be readily available to physicians through the use of electronic health information devices. ACP also advises that physicians and patients should engage in advance planning to help ensure that treatment decisions, including surrogate decision-making, are in accord with the patient's values and wishes. However, ACP warns that medically appropriate care should never be withheld solely because of costs. Further, ACP calls for medical liability reforms that include protecting physicians from patient malpractice claims when they involve patients in decision-making and don't provide services of little benefit.

Previous attempts by the federal government to control the use of health care technology included a national health planning program during the 1970s. It required certificate of need (CON) approval for new health care facilities and major capital expenditures. The national program was eliminated during the Reagan Administration, but many state and regional planning agencies still remain. The Office of Technology Assessment (OTA) was another federal agency established in the 1970s to advise Congress about the effectiveness of new technology. It was discontinued in 1995. The National Center for Health Care Technology, established in 1978, also had a broad mandate to conduct and promote research on health care technology but it too was discontinued. ACP calls for new research to evaluate the effectiveness of CON programs and to identify characteristics that are most effective (and that would be acceptable to the public) for reducing unnecessary capacity.

The benefits of technological innovation in health care are numerous and some have been miraculous. Indisputable benefits include improvements in treatments, better health outcomes, more accurate and less invasive diagnostic procedures, and reduced pain and suffering for patients. Some technological innovations improve efficiency and can reduce costs. But are all technological innovations worthwhile? Restricting adoption of technology risks impeding advances in medical science and improvements in patient care. A centralized process for determining allocation of health care resources also raises the specter of rationing in which technological services would have limited availability and patients would have prolonged waits for care.

To really bend the curve of health care costs, we will need to carefully evaluate new technologies and adopt and use them wisely. The challenge will be to balance the financial imperative to curb rapidly increasing costs without stifling innovation.

Question for today:

What steps, if any, should be taken to reduce the health care costs of technology or to assure that health care resources are better allocated in accord with health care needs?

Tuesday, September 8, 2009

Does prevention save money?

As President Obama and congressional Democrats work to re-tool their health reform effort to stop the erosion of support among voters and lawmakers, bringing down the cost is a priority. The most likely way is to reduce the subsidies to help people buy coverage or the numbers of people who would be eligible for such assistance. This, though, would move the goal posts away for the promise of "affordable coverage for all" and undermine support among liberal members of Congress and progressive voters.

Originally, Obama and his allies hoped to achieve substantial "scoreable" savings - that is, savings that the all-important Congressional Budget Office would agree reduces federal spending - through delivery system reforms designed to emphasize prevention and care coordination, supported by a robust health information technology infrastructure. The CBO, though, saw things differently - concluding for the most part that higher spending on such things would result in, well, higher spending. The promise that such spending would reduce the costs associated with at-risk persons developing more serious and complicated illnesses just doesn't make it onto the CBO ledger sheets.

Just a few weeks ago, the CBO told Congress that spending more on prevention and wellness likely won't save money. The CBO director's blog had this to say:

"Although different types of preventive care have different effects on spending, the evidence suggests that for most preventive services, expanded utilization leads to higher, not lower, medical spending overall.

That result may seem counterintuitive. For example, many observers point to cases in which a simple medical test, if given early enough, can reveal a condition that is treatable at a fraction of the cost of treating that same illness after it has progressed. But when analyzing the effects of preventive care on total spending for health care, it is important to recognize that doctors do not know beforehand which patients are going to develop costly illnesses. To avert one case of acute illness, it is usually necessary to provide preventive care to many patients, most of whom would not have suffered that illness anyway. Judging the overall effect on medical spending requires analysts to calculate not just the savings from the relatively few individuals who would avoid more expensive treatment later, but also the costs of the many who would make greater use of preventive care."

One of the reasons that CBO has trouble attributing savings to prevention is that budget rules adopted by Congress require that CBO consider the impact only for the next ten years. Anything outside of the ten year window doesn't count.

Fortunately, Health Affairs has published new research that may actually persuade CBO to look differently at the value of prevention - particularly as it relates to the value of interventions to reduce the prevalence and complications associated with diabetes and other chronic illnesses. (The research was funded by the National Changing Diabetes Program, hosted and supported by Novo Nordisk. ACP is a member of the NCDP). The authors took an epidemiological approach to estimating the value of best practices to prevent and control complications from diabetes, and found that most of the cost was recouped in a 10 to 25 year timeframe.

"For example, in the ten-year window, the cost offset for enrollees ages 41-50 was $2.1 billion: $3.6 billion in gross spending minus $1.5 billion in net spending. This means that 58 percent of program costs were offset by reduced spending on diabetes and its complications. In the twenty-five-year window, the cost offset for the same age group was $17 billion, which represented an offset of 89 percent of program costs."

In other words, over 25 years, aggressive interventions to control diabetes almost pay for themselves.

Dr. James Marks, a senior vice president at the Robert Woods Johnson foundation, blogs that the new research shows "how we can combine epidemiological science with economic analysis to better see the true costs and where we get the best value over the longer term. We need to do this more, not just in health and medical care, but for investments in our children as well."

The new research doesn't solve the dilemma of how to find enough money to pay for health reform. But it creates a promising opening to get the CBO and Congress to look at expenditures on health care interventions that have been proven to improve clinical outcomes in a different light, potentially allowing them to be fully funded without breaking the piggy-bank.

Today's question: Do you think Congress should tell the CBO to change its budget rule to look at the impact of best practices to prevent and control complications from chronic illnesses over a longer period of time?

Wednesday, September 2, 2009

Do internists really want everyone to have health insurance?

Politico and other media outlets are reporting that President Obama plans to make a major speech to communicate to the public what he wants from health care reform, and how it will benefit them. The change in approach recognizes that "we're in the eighth or ninth inning here, and so there's not a lot of time to waste" as David Alexrod, one of Obama's top strategists described the situation to Politico.

As the President re-evaluates his approach, it may be time for internists to also take a step back and consider what they want from health care reform.

If you asked me a few months ago, I would have told you that internists were generally in agreement that the current health care system needs major reform. Now, I am less sure. Like the American people as a whole, my sense is that more internists are having second thoughts about whether they really want health reform to happen. Some, of course, have already made up their minds.

This is somewhat surprising, since internists have long championed the need for health care reform. In fact, health reform was a cause celebre for ACP long before President Obama was elected.

More than fifteen years ago, ACP called for reforms to make health insurance universal and "portable" - not dependent on place of employment, residence, or health status. In the late 1990s, we published a landmark paper on the scientific research linking lack of insurance coverage to poorer outcome. The paper, titled "No Health Insurance? It's Enough to Make you Sick" found that uninsured Americans tend to live sicker and die earlier than insured Americans.

ACP developed its own proposal - released in 2002 and updated this past year - to provide coverage to all Americans with seven years. It calls for income-based tax credits to help people buy coverage, insurance market reforms, and group purchasing arrangements - not unlike the legislation being considered today by Congress. (Bills based on ACP's proposal were introduced on a bipartisan basis in the past three Congresses.)

In 2004, we published research on the costs of not providing coverage to all Americans, and in 2007, the Annals of Internal Medicine published a paper (disclosure: I was a co-author) comparing U.S. health care to other countries and drawing lessons from them. Notwithstanding the oft-stated argument in this political season that the U.S. has the "best health care in the world" we found that the U.S. lagged behind other countries on many measures of effective care and that most effective systems had certain common features - including coverage for everyone and a strong primary care physician workforce - even though they differed on how to provide coverage.

In April, 2009, the ACP Board of Regents adopted a statement on the organization's "desired future" for the health care in the United States, which says this:

"The U.S. health care delivery system provides access, best quality care and health insurance coverage for 100% of our citizens."

Not 80 or 90 percent of our citizens, but every American.

Today, we have a chance to achieve this desired future, or to at least put the steps in place to make it possible in the near-term future.

The question is: How many internists still want Congress to enact legislation to provide coverage to all our citizens? How many prefer that they fail?

I know and respect the fact that some ACP members have principled reasons for opposing elements of the bills being considered. They tell me that they are concerned about whether the country can afford to provide coverage to everyone, and believe there is too strong a role for government in the bills being considered. I also know and respect the fact that some internists, on the other side of the political spectrum, feel passionately that a single payer system is the only answer. Many internists also believe that the bills fall short - I am with you on this - on important issues like medical liability reform and support for primary care.

The current bills will be changed, and with the continued support of ACP members, we have an opportunity to get improvements in them.

But health care is at make-or-break point. Internists - like all the rest of us - will need to decide if they are willing to support the compromises needed to get legislation enacted into law that provides all our citizens with access to insurance coverage. Just as the president has to decide what compromises he is willing to offer and accept to achieve the same.

I also believe that if the current effort fails - and physicians will have a lot to do in deciding the outcome - we will be consigning tens of millions of Americans to a future with no health insurance coverage. And, as ACP said in 1999, that's enough to make you sick.

Today's question: At this critical decision point, do you think that most internists want Congress to succeed in passing legislation to provide just about everyone with access to affordable coverage?

Tuesday, September 1, 2009

Why are fiscal conservatives opposed to Medicare cuts?

Anyone looking for ideological consistency and clarity of thinking should stay away from Washington. It is no secret that liberals and conservatives alike take positions in conflict with their usual governing philosophy when it suits their political interests. Still, there are times when the bending of philosophical underpinnings is so pronounced it makes you have to stand up and take notice.

Fiscal conservatives are supposed to be all about reducing federal spending on social programs, while liberals are supposed to be passionate about defending such expenditures. Except, that is, when they don't.

Case in point: the broad opposition from so-called fiscal conservatives to just about every measure in pending health care reform bills that hold the promise of reducing federal spending.

Writing in the Washington Post, Michael Steele, the chairman of the Republican National Committee, proposes a "Medicare Patient Bill of Rights" in which he expresses opposition to Medicare savings, "First, we need to protect Medicare and not cut it in the name of 'health-insurance reform' " - and specifically expresses opposition to the $500 billion in Medicare "cuts" being considered by Congress. (Take the entire $500 billion off the table, though, as Mr. Steele suggests, and health care reform will drive an even bigger hole in the federal deficit.)

He wants to "prohibit government from getting between seniors and their doctors" and the creation of "government boards that would decide what treatments would or would not be funded" and opposes comparative effectiveness research because it could "actually lead to government boards rationing treatments based on age. For example, if there are going to be only so many heart surgeries in a given year, the Democrats figure government will get more bang for its buck if more young and middle-aged people get them."

(Even though the pending bills do not give the federal government the authority to deny coverage based on cost or age, nor does it create government boards to decide which treatments will be funded.)

Mr. Steele also opposes having the government fund discussions between physicians and patients on end-of-life care, and pledges to protect the Tri-Care for military families from cuts.

All of this may make for good politics, since the latest polling suggests that seniors are the most concerned about the impact of health reform legislation on their care. The RNC is now running an anti-reform ad targeted at seniors.

Mr. Steele's proposal has received the predictable criticism from liberal quarters but also from Robert Costa writing in the conservative National Review, who suggests that Mr. Steele's position is a "capitulation to the Medicare crowd."

It isn't only Republican politicians that have ruled out Medicare cuts; "Blue Dog" Democrats also are complaining about many of the same Medicare cuts even as they pledge to "bend the curve" on health spending. And, ironically, it is the liberals who are saying that cuts in Medicare are needed to fund the broader health reform and that the government needs tools, like comparative effectiveness research, to bring down overall health care spending.

The problem is that even though promises to protect Medicare may be good politics, they are at odds with the reality that the program is not sustainable. If the GOP regains power, it will have to deal with the governing consequences of running as the protectors of Medicare - knowing that spending on the program will have to be trimmed, no matter who is in charge.

As Simon Johnson and James Kwak write in today's Washington Post, "if you are for fiscal discipline, you should be for health-care reform. If our government cannot produce some kind of reform, that will only reinforce the perception that our political system is incapable of resolving our largest, most difficult problem -- and that is what will make investors think twice about investing in America."

Today's question: What do you think about fiscally conservative politicians who are opposed to cutting Medicare's costs? And about liberals who support such cuts to fund broader health reform expansions?