The Obama Health Reforms Begin
Quietly embedded in the giant stimulus bill that will soon become law is a powerful tool that could unlock the door to reforming America's health system -- the creation of electronic health records that can be mined to determine how patients are treated and the degree of resulting success.
Creating a system to provide evidence on what works both enables those who want to squeeze waste out of the system and offers the possibility of freeing up funds to expand care to those who cannot now afford it.
Conservatives, who fortunately have elected not to participate in the debate over the bill, are sounding the alarm in their typical overstated way assuming that anything that can happen will actually occur. They should know better.
In fact, the bill won't require evidence-based care, but will enable us to better define it. How much coercion will ultimately be required to convert research into recommendation into requirement is a question for another day. In fact, it will be several years before information becomes available.
The hours spent by Peter Orszag, who made educating Congress about wasteful medical spending a top priority during his recent service directing the Congressional Budget Office, were apparently well spent. Orszag, who's now director of the Office of Management and Budget argued that many costly interventions were a poor investment, but couldn't be weeded out until research provided a specific menu of what worked.
Language in the stimulus bill creates a structure that could write such a menu, a goal also suggested by sometime HHS Secretary and health reform czar designate Tom Daschle.
In both his current job and his past one, Orszag had the role of scoring legislative proposals, a task that requires balancing new spending, which is not rocket science, against proposed savings, which is a much more difficult chore. He's the gatekeeper charged with subjecting proposals to a reality check.
That means, to cite a hypothetical, that he'd reject assertions that a proposal to provide poor people with vouchers to health clubs would be cost-free because the resulting exercise would improve their health status and reduce the need for later medical care. That logic may hold, but there's no evidence now that supports it.
Creation of an evaluation system based on information technology is a major victory, but it doesn't mean that the war has been won. As I've warned elsewhere, the next steps won't come easily. Already a coalition of disease-based groups backed by drug money is beating the drug for choice -- a concept that wins public acceptance on issues ranging from abortion to schooling.
In this instance, they're arguing that treatment choices should be left to patients and providers working together rather than evidence-based algorithms that they choose to derisively call cookbook medicine, as if using a tried and tested recipe is somehow un-American.
But observers who think fixing America's health system has been put aside with today's focus on repairing the economy may be surprised when the dust clears.
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Here is a uniquely personal perspective on American healthcare. I just recently lost my job--which I hated, but kept only because it provided me with health insurance. The premiums I would have to pay if I kept the insurance pursuant to COBRA, are nearly $1000 a month. That is not possible. A week following the layoff, I learned that I have two completely blocked arteries which, because they are grafts from a previous bypass, cannot be treated with angioplasty or stents. My heart will also not tolerate another bypass. So the condition can only be treated medically with regular medical care. By the way, I have to stop working. Period. Even with disability, I won't qualify for Medicare for 24 months.
There's a freaking time bomb in my chest, ticking away to its ultimate conclusion. I have an internist who is everything a physician should be and more and we've already made our contingency plan. How the f**k can a situation like this be tolerated in the "greatest country in the world"? I'm not alone. Millions of people are in the same boat as me. if I hear one more right-wing a**hole whine about "socialized medicine", it's going to get violent.
Bring on cookbook medicine. It would have to be better than what we have now in our health "system." Many diagnoses and treatment modalities should follow more or less standard recommendations. There needs to be some thought somewhere as to cost effectiveness.
AnnfromCA: "I really find this approach confusing. Are we shifting away from science to anecdotal evidence? What works should be the result of tests adhering to scientific standards. Are progressives now opposed to science?"
Ann, the progressives are hoping "the scientific standards" will be universally applied. Scientific standards are not worth their salt if no one follows them. A Rand study showed 60 percent of care delivered in the USA is over-utilization or under-utilization or inapporpriate care.
The best way to implement "scientific standards" as laid down by recommendations from NIH (National Institute of Health) and other official bodies for various illnesses, is not to reimburse doctors and hospitals for inadequate care. Regards
About a third of the health-care cost of two Trilllion dollar (a year) is spent in the last few weeks of life. Most of this occurs in hospitals.
Clearly Utilization Review Committees of the hospital are not monitoring the management of these cases. The hospital's administration and board should be controlling these costs instead of complaining about reduced reimbursements from the govt or insurance companies.
The Joint Commission for the Accreditation of Hospitals or similar accrediting organizations are failing in their duties.
The American people can no longer afford to pay for their own health care. Costs have skyrocketed, while salaries have declined. This capitalist system requires workers to have a corporate sponsor, if they are to have health care insurance. Even people who do not care about their fellow man, are forced to acknowledge that the cost must be shared, for everyone to be covered. Those who are still opposed to covering everyone, even people who do not have a corporate sponsor, refuse to see that it will cost each of us about 30% less.
Ah, but those who are generally opposed to covering everyone, are those who already have coverage for themselves and their families. It's all a matter of perspective.
I could afford my own healthcare if the Pentagon gave me back my share for Bush's Wars and what he spent lining his friends' pockets. I could afford my own healthcare if I got back my share of providing tax breaks for the wealthy. Where do I send the invoice???
I have wondered why Obama pushed to have medical documentation universally computerized. I did not know (at least part of) the reason was to track what works and what doesn't. I wish he'd explained that better because now it makes more sense. As usual, he's a few steps ahead of the rest of us.
That said, the need to abolish the health insurance middle man, which is but one of the reasons health care is so expensive and so inefficient, will be like excising a large and painful growth, but once it's done, the patient will get better.
Now, if we can reign in the pharmaceutical companies so that doctors are no longer drug pushers of pills that often cause more harm than they cure, we might have a system that actually makes people healthier.
I love how all the health cost (NOT HEALTH CARE) arguments are made by able bodied people who mostly assume they will live into their 80's or 90's with perfect health. Not a single argument has been made for health care reform from an elderly, disabled, or terminally ill patient, who will likely get shafted (or worse, killed) in the pursuit of saving a buck.
Your "tried and true American recipe", Mr Jaffe completely disregards any consideration for pre-existing conditions or disability. It assumes that health care will be at a minimum and will increase over time, instead of being at a maximum since birth, and will therefore, by your recipe simply cost too much to keep many of us alive because of the exorbitant rates of medical procedures in general.
There MUST be some consideration for those of us who are born disadvantaged and who will have entire lives full of medical procedures and regimens before any of this can be considered. And that has not even come close to happening yet.
mea culpa and apologies if I left that impression. I assume that the current situation where 20% of the people are sick and thus rack up 80% of the costs will continue. the issue isn't how to care for well people because they're cheap. On the other hand, there are optimal ways to treat people with expensive chronic conditions like diabetes and it is important to determine precisely what they are and then make their use the norm. The purpose of the exercise is to free up medical resources for those who really need them. If I appear to have ignored this crucial group, I'm sorry for any discomfort that caused.
I spent many years in the Electronic Medical Record area. In fact I personally wrote a couple of EMR systems. Having said that buying this technology for the very rich medical industry, (which actually saves a practice money and pays for itself very quickly), is the craziest part of this bill. When I left the field a couple of years ago, there were over 300 vendors of EMR systems. I am sure the systems have gotton even better in that time.
Mandate standards for the records, yes, require practices to implement the systems if they want government funding from medicare, medicaid, VA or other Government sources, yes. But don't pay for the systems, there is more than enough money floating around in the industry without loading the taxpayer with the cost. IMHO Any doctor damn fool enough not to see the benefits of it by this time is to stupid to be practicing medicine anyways!
I really find this approach confusing. Are we shifting away from science to anecdotal evidence? What works should be the result of tests adhering to scientific standards.
Are progressives now opposed to science?
As long as health care is provided for a profit everyone will have lousy care and many will have no care. Health insurance should be against the law. American workers will have single payer, universal health care. We will trample anyone who gets in our way.
The real problem with free choice is that the insurance companies are already dictating medicine to Doctors based on profit not evidence. Over the last few years as I have had insurance companies shifted on me several times, I have seem the utterly arbitrary nature of formularies. I have had with help from my Dr. fight for the right to take an alternative medication for a condition because I was allergic to the medicine 'approved" by the insurance company. I was denied the cost of a dental procedure that was the newest state of the art treatment because that iinsurance company was only approving an older more damaging treatment, even though the cost was the same. My problems have been small compared to many people, but the issue is the same. Let's worry about who has really invaded the sanctity of the doctors office, the insurance companies.
Having said that, one concern that I do have, is that some doctors are moving into alternative or integrative medicine, and are actually finding less expensive, less invasive and less dangerous alternatives for treating some conditions than their mainstream colleagues. Those treatments are by and large excluded by insurance companies, and nobody will pay for adequate research, because there are no large profits for drug companies in proving that an herb can cure a condition as easily as an expensive medication. I hope the new plan accommodates research into integrative medicine and doesn't exclude it as the insurance companies have.
Well stated and all true. I have tried to ascertain how Obama feels about alternative treatments (I myself use them exclusively, having discovered them after similar experiences to yours) but I cannot get a grip on his thinking yet, most likely because he's healthy has probably hasn't had much personal experience with doctors and health insurers. But I know for a fact he listens, and I'm hoping that alternative medicine will attain its rightful place in the treatment hierarchy as the dust settles.
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