Dr. Dean's Return To My-Way-Or-The-Highway Politics

Having a medical comparative effectiveness council is fine so long as it is advisory at least until American voters have a chance to see how well it is working. And it should include among its members patients, nurses and other medical practitioners. The people who work directly with patients will be indispensable to comparative effectiveness considerations. The make-up and parameters of such a council will be important.

Anyone who is a researcher knows the difficulty involved in sampling and that research, in most areas, is for some time an ongoing process of contradictory findings leading to recommended next steps but rarely definitive conclusions. They know, too, that research regarding one population does not necessarily apply to another, that conclusions are based on statistical significance, not on individual variations that might be explained by research if it doesn't end with what seems the best answer for the most people.

Research is also influenced by paradigms. The hypotheses we generate are affected by ways of seeing - frames of reference. At times these actually impede rather than facilitate progress toward consensus. This does not render research useless by any means, but those relying on it should know the limitations.

It's critical, therefore, not to suggest that Americans must choose between the far right and universal health care as if any criticism or caution of process regarding the latter renders one immediately in the former camp. I thought we'd put behind us my-way-or-the-highway governing.

Universal health care is critical. Let's make it happen. But let's achieve it by being candid. For example, if indeed this council will not be influenced by cost considerations, then why did David Axelrod say on Meet The Press that the following with regard to the council?

We have to get a hold of this issue of cost. It has nothing to do with the, the patient-doctor relationship, it has to do with making our health care system more efficient so it doesn't implode.

If the goal of this council is only greater consistency and accuracy in doctor advice where achievable, it is possible that the findings will cost more. We may find the best procedures are the costliest. Would that be okay?

Let's be honest here. The important thing is to be sure that while we're endeavoring to achieve universal health care, we don't do so only or largely on the backs of ill people but look into the actions of pharmaceuticals, their endless lobbying, their questionable relationships with many doctors and legislators, the legitimacy of skyrocketing costs for procedures and doctor visits, and the outside influence on research findings supported by pharmaceutical companies.

What are we doing there, Dr. Dean? That wouldn't put the onus of successful universal care on patients alone but rather on those who purport to be helping them. That would be real change.

Dr. Reardon also blogs at bardscove

Comments

[RoloTomassi]

After rereading the article and comments, I thought it a good idea to point the finger at the 800 lb gorilla-in-the-room in regards to this article and the discussion of healthcare costs--the basic PRICE of healthcare services.

I'm not referring to drugs or procedures that are in question, but the very basic and indisputably needed items we all see on our hospital bills and insurance summaries. These items are incredibly overpriced, and a serious evaluations of what they SHOULD cost are just as needed as any of the comparative evaluations proposed.

There is no great mystery as to why this is so, so I won't even get into the fine points of it; the simple truth is that healthcare has no morally legitimate place in corporate profit systems. Healthcare should be priced to cover the costs of matierials, labor and operations, and held to that level. Any corporatist lackey or lobbyist that tells you such is the case now will also sell you the Brooklyn Bridge.

Addressing that issue is the biggest cost effectivity measure that could be taken. We need a national consensus that healthcare is an issue of service to humanity, and NOT a inhumane commodity sold for the profit of corporations. Universal Healthcare IS possible for US citizens IF we remove the profit motive from the equation. This wouldn't result in massive unemployment, but it would result in a huge dip in profits for pharmaceutical companies and the medical service corporations.

[Terypat]

Ms. Reardon is looking at this in terms of a business' view. As we know businesses run from quarter to quarter. I really cannot see where her expertise in actual health research lies, which does not run on business quarters profit/loss etc.

[Kathleen Reardon - Huffpost Blogger]

Terypat: Since there has been such massive trolling on this issue, much to my initial surprise until I realized how close in time the HHS nomination could be, much has been distorted and much left out. As a preventive medicine professor for years, national cancer institute fellow, preventive medicine researcher and NIH grant review panelist, principal and co-principal investigator on preventive medicine grants, as well as a caregiver and patient my efforts here are intended, as most of my blogs are, to nudge those making decisions on this issue to think past obvious routes to good answers. When the HHS issue is resolved, we may be able to return to constructive discussion and debate that help people dealing with health issues -- many of whom have participated extensively in the health care of someone they love, as Susan and David Axelrod did in halting their daughter's epilepsy. Patients and caregivers today can't afford to sit back and take direction. They are often part of the solution for themselves and, as Susan Axelrod has done, in helping others as well. The person who has come closest to why I write about health care mentioned that I am an advocate for patients having participated extensively in the health science, business, caregiver and patients sides. If those multiple vantage points help, then this and the prior blog were well worth writing.

[dsws]

The word "council" links to Howard Dean's post in favor of making more information available to physicians about comparative effectiveness of treatments -- a page that does not contain the word "council". This is bizarre. Whatever council Ms. Reardon is talking about, she wants it to include patients. This is probably also bizarre. What expertise to patients have in reviewing articles for publication, or selecting grant applications for promising research? Or if it's not supposed to happen by the support of research with results published in scientific journals, what process does Ms. Reardon think should be used to make reliable medical information available to physicians in an area where it has apparently been lacking?

[Linda Bergthold - Huffpost Blogger]

This is a pretty confusing piece. I simply cannot figure out your references to Howard Dean's excellent piece in yesterday's Huffington Post. Some of us called you out a bit in your own post yesterday about the potential impact of CER. It sounded very much like you had swallowed the right wing attack when you titled it "When Federal Employees Decide Your Family's Medical Treatment." The Federal Council meant to provide oversight to the funding for Comparative Effectiveness Research would, of course, do no such thing. It is also not a research council. The research itself will be contracted out to multiple sites and researchers, whose activities will be subject to IRBs and countless other accountability mechanisms. So I can't decide what you are arguing. Are you claiming that this new Federal Council will harm us in some way? That good research is an impossibility? That we don't need to understand more about what works in health care?
There is an excellent piece in today's New England Journal of Medicine about comparative effectiveness research. Many physicians who read the NEJM most likely support the concept. And although I understand you are not a physician, surely you respect the views of clinicians who struggle to do the right thing, often without tools or information they need.
http://content.nejm.org/cgi/reprint/NEJMp0900665v1.pdf

tODAY'S

[Eclectic Radical]

While I understand and agree with your point, Dr. Dean's point is not without merit. Regardless of your feelings, or mine, about federal control of medical research (honestly, I don't think they could do worse than the pharmaceutical companies, to be fair) I think it is important to recognize that GOP Representatives raising the specter of government control of medical procedures are not doing so for the benefit of the patients. They are doing so on behalf of the corporate interests which currently have such control. I also believe Dr. Dean is correct in his characterization of the intentions of those on the right.

I have read reform ideas by doctors opposed to true universal health care, and they are nearly always (ultimately) in defense of the for-profit medical industry that has made them successful, supported by rationalizations about government inefficiency. Have the corporations been more efficient? The one I have read that did not was actually worse, advocating free medical care for healthy people and expensive private insurance for sick people, on the principle that the majority of sick people were to blame for being sick.

I realize not everyone with concerns about the health care directions taken by the government is speaking for the right wing, but there IS a strong right wing movement afoot to block movement in ANY direction. Would you deny that, or argue that Dr. Dean is incorrect in his characterization of them?

[Kathleen Reardon - Huffpost Blogger]

Eclectic Radical: Very well reasoned. I'm on record as no fan of Rush Limbaugh. But while pushing back against such people, we shouldn't fall into their label traps or cast the net of our enemies so wide that we ensnare our friends. This is a complex issue about which we should be open to discussion and debate. Many people depend on us getting this right.

[Eclectic Radical]

I agree with you there, and I try very hard to defend my fellow liberals from each other in these matters. I'm not against vigorous debate at all. I do think, however, that in the current political climate there is some benefit to aggressive and straightforward political polemic like that of the governor. I have been known to indulge in such things. If the virtues of the elements of the stimulus under discussion are to be questioned, it is right that someone argue on their behalf. Since many of those questioning them ARE using the language of polemic, a reply to such questions in similar language might serve a purpose.

I would also suggest that it is as important not to eagerly allow ourselves to be ensnared in each other's nets. I share some of your concerns, but I don't believe that Dr. Dean's writing is intended to answer me so much as it is intended to answer opposition polemic. Particularly, polemic that is not entirely accurate in its depiction of the clauses under debate.

For the record, I think qualified doctors and informed patients should collaborate to make decisions about medical care, regardless of who pays for it. I don't want the government choosing my epilepsy drugs anymore than I want an HMO bureaucrat doing it. Yet I also think that the government should be more involved in medical research, in the manner Dr. Dean describes, because I am not certain I entirely trust the pharmaceuticals without it.

[RoloTomassi]

"But while pushing back against such people, we shouldn't fall into their label traps or cast the net of our enemies so wide that we ensnare our friends."

Hey Doc, shouldn't that be revised to read "...so wide that we ensare our CORPORATE firends"?

Ah yes, if that is what you really mean, then your position does indeed make sense.

[Zenobius]

To clarify, health care has all kinds of conflicts of interest. There are conflicts between patients and insurers, patients and doctors, doctors and insurers and everyone else with pharma companies. If health insurance is made universal and partly or wholly financed by the government there will be a conflict between the interests of patients and the interests of the taxpaying population as a whole.

Kathleen Reardon, as someone who has had medical problems tends to think of herself as a patient first.. She is arguing that our interest as patients needed to be considered first. As a diabetic with diabetic neuropathy who has lost some toes, I'm not sure I agree that the interests of patients need to come first.. But I do think that trying to duck the political question by leaving the issue to medical researchers will not work. The issues relating to approval of experimental treatments etc will have to be faced and resolved politically.

[GeorgeP922]

Obviously this is a political hitpiece.

Only two types of folks attack Howard Dean, militant members of the DLC (Rahm) and still bitter PUMAs.

Let me hit up my google, I will be back.

[Star2000dancer]

Healthcare should be not for profit. Ask JonasSalk and the honest healthcare workers.

[MyVoiceHere]

It is funny that you are citing Dr. Dean but do not clearly link to his article in a way that ordinary readers will find the link. Hiding it in the word link system does not directly point it out. I found his article to be more focused on supporting the amendment in the stimulus bill that the right has been attacking. He is also preparing the public for the fight to come on the issue of health care for everyone. I did not read any my way or the highway rhetoric in his post.

[JNagarya]

That's what we need: businesspeople, the insurance industry, and the pharamceutical industry running the health industry and making our medical decisions for us.

Oh, right: that's what we have now.

Er, "Professor": look up the "appeal to authority" fallacy. (Clue: I don't trust the unqualified to make my health care decisions for me, or to tell the medical industry the best way to run medicine.)

[RoloTomassi]

Dr. Reardon, please, come on, this is disingenuous at best:

"For example, if indeed this council will not be influenced by cost considerations, then why did David Axelrod say on Meet The Press that the following with regard to the council?"

""We have to get a hold of this issue of cost. It has nothing to do with the, the patient-doctor relationship, it has to do with making our health care system more efficient so it doesn't implode.""

What IS your real agenda in regards to this subject? You cannot convince me that as a physician you did not immediately grasp his meaning, or that you see this as contradictory in nature; clearly distinguishing between valid medical products, procedures and services and those that are ineffective, repetitive yet more expensive, or flat out unnecessary for adequate treatment will save money. It is equally clear that eliminating bogus products and procedures IMPROVES overall care--there is no conflict here.

[oldguru]

Dr. Reardon is not a physician. She is a professor of Management in a business school. That explains why her outlook isn very different from Dr. Dean who IS a physician.

[rssrai]

What is the difference between the insurance telling doctors who they can treat, and government telling doctors who they can treat? The difference is that government will be looking at what is best for the patient, not what is best for the insurance company and their stockholders.

[maxfax]

We need relief from the greed of insurance companies, and this may give it to us. Isn't this the 2nd such themed blog by this writer in the same number of weeks?

[Donkslayer]

Are you sure? What it there's a budget shortfall?

[MJinCanada]

Canada has had universal health care for over 40 years. The government in no way dictates whether a patient gets angioplasty or a heart transplant, whether or not someone over 65 gets knee replacement surgery, or whether or not a high-risk pregnancy results in a lengthy hospital stay or a termination. These are all decisions that the patient and doctor agree upon, and cost is not the driving factor.

[Maxiesid]

I was trying to figure out what your headline meant and even after reading your post I still don't quite understand why you are so snarky about what he is saying. I understand your whole; "well, it might be this way, or it might be that way and we can't tell the outcome, but we need to try something else, which may or may not work, and we researchers need to be able to research independent of cost, etc etc etc" and you do an excellent job of double speak, it almost sounds as if you have a specific point to make when actually the culmination of the whole post is that you just wanted to be able to write..:'What are we doing there, Dr. Dean? That wouldn't put the onus of successful universal care on patients alone but rather on those who purport to be helping them. That would be real change' The real change would be to actually see people trying to get together to get something accomplished, instead of trying to promote themselves and their agenda. Dr. Dean is right, by the way, and the best thing that could happen to this country would be for him to get the post heading the HHS.

[RoloTomassi]

Yup, I have to say that after reading both recent posts on this issue by Dr. Reardon, my biggest impression from having read them is that she doesn't like Dr. Dean.

[maxfax]

We may have a consensus on that.

[mjc]

Have to agree with her, if that is true. This is an MD who to avoid serving in the military took his X-Rays to his draft board to show them his bad back and to disqualify him from service. He then went skiing in his favorite state, Vermont. Sure, lots of men avoided service but this is a doctor who used his own professional credentials to get himself excused and then demonstrated just how little those credentials meant to him.

[mjc]

Making the health care industry more effective is probably going to be a dream forever. My father was a doctor in the Air Force and constantly railed against socialized medicine and any government involvement in health care. He never seemed to know that he was a part of a government medical system and that we, his children, were under such care for much of our early years. Good care, too. Every dentist I have ever seen, for example, comments on the good condition of my teeth. And no matter where he was posted to we always had the best vaccines to protect us; prevention was the keyword of military health care. Yes, there were doctors who were OB/GYN practitioners in private life and general medicine in the Army or Air Force who complained bitterly but nevertheless performed quite well in another area. Our father ran Travis AFB hospital at the height of the Korean War and I don't think there many patients who complained about the quick and effective care they received getting out of Korea, into Honolulu and then to Travis sometimes within 24 or 48 hours of receiving wounds. There was also perhaps the first awareness of the mental stress on soldiers in those AFB hospitals. But the transfer of energy to medical care came during a protracted war and perhaps that is the only way socialized medicine could happen again.

[ShockedSHOCKED]

As a humble epidemiologist and with all due respect to Dr. Reardon, let me say that Cost Effectiveness Research is sorely needed as part of health care system reorganization. The US spends far more than any other country in the world (16% of GDP) for, at best, mediocre health care outcomes, at least 50% more than the next most costly country. Care is already rationed on a de facto basis between those with and without good health insurance. Cost Effectiveness Research is one tool for changing the costs and the outcomes. The system wide changes that are needed will be costly and difficult. Not to do them will be more costly in terms of money and human suffering.

As for the characterization of research, Dr. Reardon make a few good points but they are paired with gross distortions. Yes, research is hard to do well. Yes, findings are influenced by researchers' paradigms. But it is long past time for us to test whether older, cheaper drugs might not be as effective and safe (or MORE effective and SAFER) than the new and very expensive drugs being pushed by drug manufacturers. This could have prevented many of the problems we saw with Vioxx. These insights won't come on the backs of the poor, but can instead increase the monies available to broaden care for them..

[Kathleen Reardon - Huffpost Blogger]

I don't see a disagreement. My point is about how to do this effectively and not to lose sight of other ways of reducing costs that involve abuse. More effective, safer, and less expensive are all good. And so are learning best practices as in the best procedures to use when people arrive at emergency rooms. All good. No argument with me.

[oldguru]

Other Countries, in fact most of the rest of the world, have models of universal health care that we can take examples from. Dr Dean instituted a program in Vemont that seems to work pretty well. It is not rocket science to get a program put together that will cost less than we are spending now, and deliver health care that is superior to what we are getting from the insurance companies and Big Pharma currently. Let's face it, the main reason that we do not have universal health care now is that the lobbies of the Insurance industry and Big Pharma have a strangle hold on our government. Get rid of lobbies, and we will have sensible health care in this country.

[oldguru]

The rest of the world has some form of universal health care that we can study and take some ideas from. It is not rocket science to set up a program that will deliver health care for everyone at lower cost than we are paying now, and is superior to the messed up health care that we get (if we are lucky) from the Insurance industry and Big Pharma. Get rid of the stranglehold that those lobbies have on our government, and we will have better health care.

[FaceReality2]

"Care is already rationed on a de facto basis between those with and without good health insurance."

Why don't more people understand this?

[philistine]

Good point. I still trust Dr. Dean more than the industry shill that will probably get the post of Secretary of HHS.

[larry278]

I take it that you mean Dr Gupta or isn't he being considered for the position of Secretary of HHS any more?

[pollyannish]

I thought he was only being considered for Surgeon General?

[philistine]

I'm assuming that someone other than Dr. Dean will get the post, because after an upsurge of netroots support for Dean after Daschle backed out, there's been no apparent enthusiasm for Dean's candidacy from Obama administration officials - or anybody else. Rahm Emmanuel opposed Dean as chairman of DNC, and I think he's torpedoing Dean's candidacy for HHS Secretary. Emmanuel is known as more of an insider than Dean, so I think that Rahm wants an industry guy instead of a medical guy like Dean. I could easily be wrong. I hope I'm wrong, because I think Dean would be an inspired choice.