Two Republican Senators, both physicians, have begun a series of webcasts to hold forth on health care reform and answer questions from citizens. Given their status as conservatives and as physicians, Doctors for America has decided we should provide a counterweight to the two Senators and try to correct any misinformation we see in their statements.
The overall theme running through the webcasts are that bureaucrats are bad and that the only problem with health care in America is that it is too expensive and, don't listen to those socialist Democrats, we Republicans have a plan to fix this all. We'll give you a hint, it involves tax cuts. So,away we go...
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First, the players. Senator John Barasso, from Wyoming (smallest population in US, 533K), is an orthopedic surgeon.Senator Tom Coburn is a family physician representing Oklahoma (pop 3.6 Million, 28th), who apparently devotes much of his practice to OB-GYN and delivering babies.
The Senators discuss Medicare not paying for preventive services, specifically blood tests for screening. Well, first , it is not true. The Medicare Modernization Act added many screening benfits to the program, and as a little bit of instruction for the Senators, we, as citizens, can change and update our services provided by Medicare or other public plans by appealing to our government. It is also worth noting that preventive services are a high priority for, well, everyone involved in this debate and provisions in the HELP and House bills that would require insurers to cover preventive services rated A or B by the USPSTF. That's putting real teeth behind prevention rather than invoking prevention as a rhetorical trope.
Barrasso specifically said Medicare would not pay for screening blood tests of a preventative nature. He said blood testing panels were being done at community events, fairs, etc. So presumably these people were paying out of pocket. They do that around here too. What does that tell you? PRIVATE INSURERS WON'T PAY. Or it's just easier to go to the fair and avoid the co-pay from the doctor to get the order and from the lab. There are now screening vans with ultrasound machines doing vascular screening as well, presumably for the same reasons.
Other countries do far better at prevention because everybody is in, nobody is out. A physician interviewed for a piece in Consumer Reports said he advises his patients to NOT GET screening tests if they have any uncertainty about their insurance situation because they should lose their coverage or be denied if they switched jobs.
The Senators felt strongly that no one should lose their home or go bankrupt due to medical expenses.Welcome to the party, Senators! Bankruptcy due to medical bills is a uniquely American problem and it is a shame on us that it continues to be so pervasive a problem. Tax cuts will not solve this problem.
And that concern only addresses the most severe financial costs of our "system." What about life and death and health and wellness? The
difference between the Republican approach and ours is that we don't believe rearranging the deck chairs on this Titanic and eventually, maybe, possibly, perhaps achieving Universal health care in 15 or 20 or 30 years is acceptable. How many people have to die before they get it? The Institute of Medicine estimates 18,000 deaths per year due to lack of insurance. That's close to a ¼ million since the Clinton reforms were sunk in 1994.
Coburn also argues for cost transparency as a remedy for high costs. This is that "tweaking" mentality Republicans continue to embrace (or cling to!). Avoiding the big picture, focusing on little diversions will not achieve universal, quality health are for all Americans.
Senator Barasso notes that, "Half the all the money we spend is on just 5 percent of the people. And these are people who tend to eat too much, exercise too little, and smoke," and ridicules Senator Kennedy's efforts to include funding to make our towns and cities more friendly to walking and exercise, and improving school nutrition standards and exercise programs, perhaps the most important things that could be done to improve the overall health of Americans. The short-sightedness is embarrassing.
But, more to the point, stand in a physician's shoes and see the devastating costly illnesses like autism and schizophrenia and cancer and ALS and MS and on and on that have nothing to do with vice, and explain to them that we can't provide universal health care because it's more important to punish people with bad habits who don't live like we think they should. And it is worth pointing out that "good" behavior, in terms of healthy living, are directly related to income and education, a couple other things that we, as a country need to work on elevating for the entire population. Perhaps after we get universal access to healthcare, then we can go after the "undeserving sick."
The Senators point to Safeway Grocery Company, which emphasizes prevention, including incentivizing employees through money to improve health behaviors. We concur and applaud Safeway for their efforts. The President and Congress should push hard to encourage wellness programs like these, but for everyone, not just those lucky enough to be working for responsible companies like Safeway. We would also advocate Comparative Effectiveness Research funds for extensive trials of different wellness strategies to help guide us as physicians.
But, don't forget, if you don't have really good insurance, there are no incentives to be offered.
The Senators next take a question from a retiree, apparently doing well enough, bless her, to retire before she has reached Medicare age. She asks how they are going to keep quality up and costs down. Wait for it…Tax Cuts! And they'll let you buy insurance across state lines, because "we know that works." We don't know how they know that, but would be interested to hear it. This is another superficially appealing but unworkable strategy that would make a Wild West unregulated system even worse. Do we want patients and providers to discover that an alleged health insurance policy is a mail drop in the most minimally-regulated state an insurer can find? What happens when patients need to appeal or negotiate payer decisions? If you like the credit card market, you will like this. This is a race-to-the-bottom policy that would gut state regulations without creating a strong federal replacement. Additionally, who can intelligently pick among the three or four plans we have to choose from now, for goodness sake? The average consumer is supposed to figure this out? This is a recipe for massive failure along the lines of the current economic crisis or the S&L collapse. So, of course, the Republicans are all for it. "What could go wrong?" Phil Gramm or Alan Greenspan might say.
But to get back substantively to the tax cut comment, although they support tax deduction for individual coverage to parallel group coverage, the problems in the non-group market go much deeper than a tax deduction. High administrative costs, poor coverage, and extensive underwriting make this a fundamentally broken market that requires major reforms. A $2700 tax break doesn't help you buy a $15K policy unless you're in the top 1/5 income earners or so.
We also note that the questioner only has a few years left to reach the Promised Land for so many Americans living on the edge of financial and health care disaster, Medicare age. Because we notice there were no questions from an uninsured person, a disabled person, or someone who is visibly poor.
Giving credit where it is due, the Senators make a good point about paying for procedures rather than health. We agree, and we must align our incentives with outcomes, develop accountable care organizations and perhaps, emulate those commies at the Mayo Clinic and not reward the best billers and those who do the most procedures, but those who provide the best patient care.
The Senators argue for not allowing anyone-a government bureaucrat or an insurance bureaucrat-- to get between you and your physician. Again, credit where it's due, as they at least recognize that private insurance bureaucrats are the problem, but they have invented the bogeyman of government bureaucrats where none exist. Who is more likely to get between you and your doctor: Your parent's Medicare or your private policy? Their reference to insurance bureaucrats acknowledges public anger on this issue. Yet the substance of Republican opposition to health reform benefits the insurance industry in every particular: opposition to the public plan option, support for Medicare Advantage giveaways, not to mention giveaways to the pharmaceutical industry that reflects a similar mindset.
The Senators express grave concern that there will be someone with a book who will overrule doctor. (See above: There already is!) They also talk about how medicine is an art and not always a science, how the right thing to do is not always what a book says to do. Actually, the problem really is not that there is an under-emphasis on the art of medicine as much as there is a limitation on our science. We spend countless billions of dollars on basic science and pharmaceutical research, and yet we spend precious little on how to translate that research into knowledge and practice that we can apply at our patients bedside. And this is the point of the Comparative Effectiveness Research that conservatives have painted as a diabolical plot to drown the art of medicine in a Norquistian bathtub.
And it is worth pointing out that the concern by some physicians about more rigorous knowledge of how to manage patients breaks down largely, but not completely, on generational grounds. An older physician might refer to "cookbook medicine,", whereas a younger one trained in the advances in patient safety such as the Toyota model of improving processes or the aviation model as applied to patient safety, will utilize the techniques that are known to improve patient outcomes. It is alarming that one of the few physicians in Congress, Senator Coburn, believes that evidence based medicine results in worse outcomes. This is a disappointingly anti-intellectual approach to science and medicine.
When you get past the scare tactics, Republican and Democratic experts alike recognize that we are spending huge amounts of money on treatments of uncertain value, while we fail to provide treatments that would provide great benefit. Both physicians and patients need unbiased and rigorous information about what actually works.
We were very pleased that the Senators acknowledged the corrosive effect of direct to consumer advertising on the practice of medicine and escalating prescription costs.
We are surprised that, in the context of two Senators who seem to believe that we need to constrain medical costs, their alarm at Medicare's recent decision to limit the use of video colonoscopy. Medicare advisors have determined that, according to the AP,
"the evidence is not sufficient to conclude that screening CT colonography improves health benefits for asymptomatic, average risk Medicare beneficiaries" (Wall Street Journal, 5/13). The CMS memo also noted that any growth can be removed during the standard procedure but not during the virtual method (AP/Philadelphia Inquirer, 5/12). CMS officials said that virtual colonoscopies are a "promising technology," but that additional studies that focus on its benefits to the population covered under Medicare are needed.
The Senators claim that doctors will do a good job on cost if they are unconstrained. Specifically, Coburns states that "Doctors will do a good job on cost if we're given a free hand to do what is best for the patient." This is, of course, belied by mountains of evidence. But more importantly, if we do not start restraining spending on medical procedures of dubious value, how do we ever expect to control health care spending?
Rationing care is the chief method of maximizing profits and reducing the "medical loss ratio" of both for-profit and not-for-profit health insurers. We think the Senators' outrage is sorely misplaced.
We are pleased that the Senators chose to look at Australian health care, even though they think it is cheaper, but worse. For the longest time, it seemed Republicans only knew of three systems: UK, Canada and the mythical communist gulag that America's health care will become if any substantive change is made to the health care paradise under which we now operate.
For the record, while Australia is one of the countriesthat has longer wait times than we may be used to, they stilloutperform us in health care outcomes, and dobetter on preventing deaths and Australian doctors like it.
But, let's ask Coburn and Barrasso to talk about the two best systems, France and Germany and ask them why we can't use them as strong examples of how to improve things here. We think Teddy Roosevelt nailed it pretty well almost a century ago:
"It is a mistake for any nation to merely copy another; but it is even a greater mistake, it is a proof of weakness in any nation, not to be anxious to learn from one another and willing and able to adapt that learning to the new national conditions and make it fruitful and productive therein."
There is more, but we need to save something for the next episode!
Yours Truly,
Doctors for America
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