Thursday, November 19, 2009

A good (and not so good) day for health reform

Yesterday's unveiling of the revised Senate bill on health reform ordinarily would have constituted a good day for health reform, moving the ball yet another few yards closer to the goalposts. The Washington Post reports that Senate Democrats were "jubilant" that the CBO estimates that the new bill will reduce the deficit by $130 billion over the next decade while providing coverage to 94% of uninsured legal residents. Majority Leader Harry Reid (D-NV) plans to bring the bill to the Senate floor on Saturday for a procedural vote, requiring 60 votes, to halt a GOP filibuster and to allow debate on the bill itself. A final vote, which would require getting 60 votes to overcome more procedural hurdles, likely will not take place until December. ACP is in the process of analyzing the bill compared to policy, so I will have more to say about it in a future blog post, and we also will post updated information on

At the same time as Democrats were celebrating the release of the Senate bill, the flap over the new mammography guidelines from the U.S. Preventive Services Task Force (USPSTF), published in ACP's own Annals of Internal Medicine threatened to undermine public support for health reform. Now, I am a health policy wonk, not a clinician, and have absolutely no opinion on the guidelines themselves, but I can comment on the political fallout from the guidelines.

In one sense, the mammography guidelines have absolutely nothing to do with health reform. They were in the works long before the current administration took office, they would have come out even if health reform was not on the national agenda, and the guidelines themselves are purely advisory.

But in another sense, they have everything to do with health reform. The House and Senate health reform bills would require that health insurers provide coverage for preventive services recommended by the USPSTF - although insurers would be allowed to offer additional benefits. The Chicago Tribune notes that research on comparative effectiveness is a "central idea in the push to improve American medical care and control its cost: experts studying the effectiveness of treatments and procedures to determine which work best."

KevinMD opines that health reformers should be very worried about what the backlash to the guidelines means for the future of comparative effectiveness research: "If recommendations from an entity like the USPSTF - as non-partisan and robust as it gets - gets so much resistance from doctors, patients, and even the government itself, findings from a comparative effectiveness body stand absolutely no chance of changing medical practice."

NPR reports that Republican opponents of the Democratic bills have used the controversy over the guidelines to argue that it will lead to rationing and "the insidious encroachment of government between the patient and their doctor" according to Rep. David Camp (R-MI). (Notwithstanding the fact that under the bills, the USPSTF's recommendations would still be advisory, or that the independent scientists on the USPSTF are hardly government bureaucrats.) Seeing the threat being created by the backlash, and fearing that the GOP criticisms will resonate with votes, the Obama administration distanced itself from the USPSTF guidelines in a statement attributed to HHS Secretary Kathleen Sebelius.

All of this goes to show why reforming the health care system is so difficult. Scientists would like to believe that we people can rationally make health care decisions based purely on science and evidence. But health care is very personal and emotional, and even the best science will be rejected if people sense that it will take decision-making away from them or limit their choices. And if taxpayers are going to subsidize coverage, decisions will have to be made on what services will be covered, and as this incident shows, such decisions will not come without generating intense debate and opposition.

Today's question: What do you think the flap over the mammography guidelines means for health reform?


Robert J. Sobel, M.D. said...

It was strange last month (Breast Cancer Awareness month) to use my usual line, but I did. To women in their 40's, I reminded them that it wasn't the craziest notion ever not to get a mammogram annually. Most breast cancers in the 40's are discovered by physical exam, mammogram benefits are marginal, radiation will affect later life breast canncer risk, and guidelines should not be applied in a standardized manner.

This latter point is obvious to front-line practitioners but may escape the well-meaning politician and others with various stakes in the health care pie. The danger of the quality rhetoric becoming reality is that it requires enforcement. It would create another bureaucratic imperative. This, we cannot afford.

I would say we must streamline the legislation. Let's see if we can keep it as straightforward as possible. The mandate and universal coverage are key. Divestment from shareholder status and a state basis for insurance (as already exists, but with federal guidelines and elimination of ERISA shelters and anti-trust protection) should emerge from the exchange. Let old-fashioned BCBS structures return. Level the field a bit. Fix Medicare with some strategic moves on fee-for-service payment and drug financing (Regulated Royalties for the latter).

Health reform will pass. Rhetoric will be heated, over-the-top, emotional, and contain within it important considerations for striking the intelligent balance we need in the final bill. I would hope some of our commentary over these months will guide these final considerations. Speak now or forever hold your peace.

Arvind said...

It is interesting that one of my patients commented yesterday "since the government does not to pay for mammograms, they decided to lower the standards". Although I am not sure if this is the truth, I agree with the perception. This is exactly what CER initiatives will bring.

The basic idea of having taxpayers as stakeholders is very troubling, just as having private insurers as stakeholders.

james gaulte said...

Your comment that USPSTF panel would still be "advisory" is at odds with the detailed analysis of the house bill wording that can be found at the blog Covert Rationing written by DrRich.The entry is dated Nov 19 and entitled "Sebelius is wrong-the USPSTF is setting policy". He quotes page and section and it seems clear that their recommendations under HR 3962 are much more than advisory.

Harrison said...

Mammography screening for breast cancer leaves a lot to be desired at all ages.
It leads to excess surgical procedures and treatments and morbidity and mortality that equals and probably even surpasses any gains in breast cancer related deaths.

Women are right to feel slighted by the health care establishment -- but not by this USPSTF recommendation.
They should feel slighted by the lack of a good screening test for such a significant disease entity.

The USPSTF is suggesting that women and their physicians should engage in informed and shared decision making processes.

Health care reform can help move us closer to that.
It can structure payment reform to encourage physicians to understand guidelines and talk with their patients about them.

Of course it will be a political football.
We don't have a contemplative political process.
We have an adversarial political process.
Medicine is done collaboratively and in stages.
The law and the political system requires taking sides and arguing positions, and winning.

It is disheartening to see Ms. Sebelius feel a need to distance the administration from the informed position taken by the USPSTF.


ryanjo said...

Assumptions by the USPSTF:
1. Checking half as often will result in half as much "harm" caused by false positives. Nonsense, the same false positive densities will still be present, & will still result in the extra spot views and biopsies, etc.
2. Screening 1,300 women to save one life (age 50-59) is an acceptable cost but screening 1,900 (age 40-49) to save a life is not. This is science? No, this is arbitrary.
3, The insurance industry will graciously allow the choice for a yearly mammogram to be between a woman and her doctor. Based on the several forms I complete daily to avoid forcing patients to change an effective medication to one that the drug plan gets more cheaply, unlikely. Who served on the USPSTF? Certainly not practicing physicians.

To quote the USPSTF report: "There is convincing evidence that screening with film mammography reduces breat cancer mortality." Given the small difference in numbers-needed-to-screen, is your patient's life in her forties worth less than someone else's life in her fifties?