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When Federal Employees Decide Your Family's Medical Treatment
I'm not as sanguine as some about a council of federal employees who will determine which medical treatments are more effective. I understand something must be done about medical costs, but from the time I read plans for bringing the costs of chronic illnesses under control on both Clinton and Obama's websites, I've wondered if this isn't doublespeak for take-it-or-leave-it medicine.
Having been a professor of preventive medicine for many years and having had both cancer and Parkinson's disease, at first I felt it somewhat self-serving to write about this. My husband reminded me that it's self-serving for people to write about social security because they'll one day receive it. So here are a few cautionary thoughts.
When I heard David Axelrod speaking of the planned medical council on Meet The Press, his tone and words were not reassuring. He said "I think most Americans want us to do something about that," referring to medical treatment inefficiencies. I doubt very much that most Americans have a clear picture of what this council could mean for their future medical care. He added that the "council is going to be looking at best practices, at, at, at what, what is working and what isn't and, and making recommendations about how we proceed, particularly within the, the, the federal system."
I understand that David Axelrod is personally familiar with how difficult finding a cure for diseases can be and that is reassuring. But there are still dangers lurking here. One of them is that "best practices" can be seen as falling along a straight line or a within range. The former is dangerous.
Researchers are often quite distant from the patients they study. And many prefer it that way. If we are going to have a council of researchers who keep at arms' length from patients, who seek answers only or primarily for those whose symptoms fall neatly under the inner regions of the bell curve, the many diseases about which medical experts know very little (orphan diseases) and the patients who do not respond predictably will likely, as outliers, suffer unnecessarily.
My political antennae sense some potential seight of hand here. The intentions are likely good. But I've seen and served on research boards and bodies and I wouldn't want most of them deciding my children's future medical care options. Whenever patients are not part of the equation, because they muddle things, the results are skewed. And having spent years working with doctors as a researcher and partner in my own health care and that of those I love, I'm sensitive to the strong views held by many with the loudest voices.
Medicine is a very inexact science. No council can change that fact. It could easily become a smokescreen for clearing a treatment path down the center of major illnesses putting lives in jeopardy that might be saved with some common sense and flexibility. As annoying as patients themselves can be to researchers, if their voices are not heard even a well-meaning council will bring more harm than good.
Medical costs must come down. But as we've learned with business bailouts, better to do it right early on, to anticipate abuse, than to be digging our way out of a mess for years to come.
Dr. Reardon also blogs at bardscove.
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I don't understand all this talk about the gov't telling us what medical treatment we have. I was an RN for 30 years and welcome the switch to evidence based medicine that has slowly been working its way into general practice. For example, for patients presenting as heart attack vicitms in the ER, there are now standards of care....based on solid patient evidence. We track whether or not a patient gets an aspirin, a beta blocker, serial EKGs to pick up slowly developing infarcts, a trip straight to the cath lab to reopen a blocked artery. Years ago, we plunked patients in a CCU and "observed " them for several days while the heart muscle essentially died. Becauseof evidenced based practice patterns, we now treat cardiac patients in an entirely different manner and save many more lives. If fostering evidence based medicine is what the gov't wants to do it,,,,,,I'm all for it!
There are several posts on this article by insurance/AMA lobbyists; pay attention,t hey're not hard to spot.
See Paul Jenkins's Profile
"I'm not as sanguine as some about a council of federal employees who will determine which medical treatments are more effective"
So we should just continue to leave it up to insurance companies?
See Kathleen Reardon's Profile
Certainly not.
Dr Reardon -- it is disappointing that a medical professional like yourself has chosen to distort an issue as critical as comparative effectiveness research. Contrary to your title "When Federal employees decide your family's medical treatment", this piece of the Stimulus legislation would do no such thing. The purpose of this legislation is to help the public, your patients,and you to better understand what works in medicine and what does not. I'm sure you are aware that we have very little actual evidence about how to effectively treat most of our diseases. This is the opposite of "take it or leave it medicine." It is an opportunity to really learn something about what is done in medicine, and I would have expected you to wholeheartedly support it. The Federal Council itself has no power to impose treatments on phyisicans like yourself. The council would be composed of representatives of various federal agencies that deal with health care, and the function of the council would be to provide oversight to this funding. With that much money at stake, we all want oversight, and we want that oversight to be objective.
I commend to you and your readers the excellent post by Dr. Howard Dean in today's Huffington Post -- http://www.huffingtonpost.com/howard-dean/the-far-rights-all-out-of_b_167628.html -- he points out the way in which the right has taken this issue and blown it all out of proportion.
See Kathleen Reardon's Profile
Linda: Please reread my blog before accusing me of distortion. I'd rather not be part of the "our-way-or-the-highway" politics of the past. If that was not your intention, I'm relieved. Recommendations and cautions should be a part of all discussions having so many ramifications for people in ill health. I'm delighted that you are so pleased with Dr. Dean's comments. I doubt he meant to imply that anyone expressing concern must be a right-wing Republican. Our goals are the same. My comments refer to process. As I said, please reread as I prefer not to be used to advance any agendas, even those on my side.
Such will likely be the knee-jerk reaction, doc, because as you can see by browsing these comments, the lobbyists are out in force and are doing their best to misconstrue the intent of efforts to review drugs and procedures; they know their clients stand to lose a lot of revenue from selling products and procedures that are useless and repetitive.
For many who are intimately and constantly involved with the current state of US healthcare as patients, this looks to be a promising progression away from insurance profit-based healthcare decisions.
As many have pointed out of late, the depth of polarization in US politics is nearing the point that bi-partisan agreement on crucial issues is highly unlikely, and as a result much needed legislation is rejected or politically mutated to the point of uselessness.
All of that said, you [or anyone else] will likely not be afforded the luxury of a viable middle ground from which to broker more realistic and practical approaches; you, and the rest of us, will simply have to choose to change the system, or let stand as is.
I think you know how the majority of us feel about that.
As a former RN Casemanager who worked for hospitals, calling insurance companies to get hospital care and treatment authorized for payment, may I offer the following concerns... we don't want the current administration to come up with mandates for treating certain diseases, and we do need to have strict safeguards for all of our electronic medical records so that they can be utilized only by designated health care providers.... not merely a national data bank for big brother or any other entity.
Since people respond differently to treatment (I can take an aspirin for aches and pains, but my husband is deathly allergic to aspirin), so we don't want the government saying what medications will be authorized for payment for specific diseases. Our physicians who have been highly trained, and who know us and our conditions really are the ones who need to make these decisions, not an employee of the government, and not an insurance company whose CEO makes an ob.scene salary, and who have come up w/ mandates for how health care is to be provided (or it won't be paid for).
Ah yes, but as an insurance agent I can tell you insurance company claim departments practice medicine on a daily basis. I have known them to prescribe medications, paying only for generic when the doc prescribed brand name, by being willing to pay only for a blood pressure med that did not work well and refusing to pay for the one that did. This in spite of all appeals. It's their ball so it's their game. Could this be improved?
Now, as to our highly trained docs, there are docs and then there are other docs, and you know that. If the guidance is as to efficacy, what would be wrong with that? Right now an attractive, well dressed young female detail person in a some male docs' offices could get them to prescribe her company's brand of meds, regardles of its merit. Is that a better system than to have a panel advise on expected outcomes?
Dr. Reardon, Your post is much appreciated. As a retired RN BSN (who spent a good many years in Utilization Review, after a broad background in hands on nursing in public health, med-surg-OB nursing) am also very concerned in hearing the rhetoric about healthcare. Everyone in America needs to contact their representatives in DC to ask them to guard against letting anybody except their MDs direct their medical treatment regimen. Physicians who spent years and hundreds of thousands of dollars in their training, are the ones who need to be calling the shots. Human beings do not lend themselves to be pigeonholed. The treatment which works for one person, may not work for someone else with the same diagnosis. All men/women/children are NOT created equal when it comes to how their bodies respond to a particular drug, or treatment. We are "fearfully and wonderfully made", and some clerk with an ear bud, sitting behind a desk, in front of a computer that has all the questions and answers programmed into it, should not be allowed to say what health care will or will not be paid for.
doctors rarely call the shots anymore. I'd rather have the majority of people on government plans then deal with the unknown untrained bureaucrats of my hmo
at least with the government I can call congressmen and write letters. I have cronic and a rare expensive illness and I have to read constantly to keep up and make sure my doctors are not just giving me the treatment they get the least flack from insurance to prescribe wether it works well or not
I love it when a generic works it costs me less but I want to keep working and side effects can push me out of work
I am going broke from co pays that make it much more expensive for me to treat cronic and rare disorders then a car accident and surgery. i have a good job and average insurance coverage but I may have to go bankrupt from medical costs and I still can't afford my medicine all the time or go to the doctor at the end of a month, and forget about the dental care I need I cant afford it even with insurance i spend too much on co pays to keep up with anything else I need
given a few protections I'll take the government over private insurance anyday heck I'd save money with medicare prescription coverage at least there is a limit on how much you have to spend
For anyone to pretend that MD's have the time resources or tools available to streamline and process the massive amounts of efficacy testing data, gained through the hundreds of clinical testing regiments performed daily throughout the world is a ridiculous notion. People like "dessertsfirst" on this blog who work within the "provider" networks of doctor offices, and clinics are not in a position to access the VOLUMES of data captured by CRO's and institutions who are testing at various sites globally every day of the week, I work in clinical research for pharma products, and I can guarantee you that no MD is privy of the complete dataset when it comes to treatment outcomes, how could they be, unless they can sync to the matrix. They do not have the opportunity to make a statistically legitimate accessment of treatment effectiveness over the broadest range of patient types, but the data is there, America is not a group of one "demographic group" called Americans genetically speaking, African Americans differ from Caucasians, Latinos from Asians, Native Americans from Eastern Europeans. This is GOP narrative creation designed to build a case on fear for 2010
Hook, line and sinker!
This is a partisan strategy designed to spread cynicism and fear throughout the public, in this proposal the medical council will not in any way granted the authority to disparage, deny, or determine what treatments MD's must or rather should be utilizing for their patients. This council's intention is a worthy and necessary goal, independant statistical analysis of efficacy and results data, which is available but not required for MD's to utilize in their own independant decision making process. The individuals on this council will not be politicians, or pharma lobbys they will be medical professionals with the experience and forsight to work within a framework which fully acknowledges and considers the variable nature of treatments on various demographics, but for you to suggest that any individual MD with limited access to the entire scope of demographic groups, is in any position to access trends over the entire population without this tool, then I have a road in Alaska to sell. Yeah, of course he could read every medical research journal he could find, but if a program such as this worked in conjunction with research institutions and CRO's across the world, the comprehensive insight gained would be invaulable.
Well, let's bring medical costs down the right way, shall we; The obvious thing to do is remove the insurance companies. We're GUARANTEED a lowering of costs that way.
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Oh yes lets remove the insurance companies. We'll just replace them with the government run medical programs. You can bank on the feds lowering costs......With Joe Blow government flunky on the medical necessity board you can be sure they'll lower costs by deciding YOU really don't need that life saving surgery. And the costs will be lower because your physician won't want to incur a fine for doing a procedure deemed "medically unnecessary"
ENJOY!!
Do you not realize that the health insurance companies already do what you describe?
Sense it is a given that someone, somewhere will have to make such decisions in ANY system, do you really want the motivation of DENYING you coverage for profit to be the basis on which these decisions are made?
That's how they are made now, and it is NOT a reasonable way to approach healthcare.
First, the insurance companies are already deciding who lives and dies based not upon medical knowledge, but upon cost.
Second, since the Federal medical insurance program called Medicare currently spends around 3 cents out of every dollar for administrative costs, which is compared to the BEST in the industry being more than 15 cents, and the average of 30 cents, and the worst spending more than 50 cents out of every dollar!!!
Of course we need more evidence-based medical practice. Also broadly accepted guidelines that will help assure that physicians stop ordering unnecessary procedures and tests in order to avoid possible lawsuits. Also a look at cost effectiveness for all procedures and medications. Also a look at disposables.
No matter what they may say, physicians cannot help being influenced in their decisions by how much they will get paid for them. Not their fault, it is human nature. I have several personal examples of this, one of which was an unnecessary overnight in the hospital so a referring doc could see me in person and get paid.
Professor Reardon, I don't want to accuse you of being disingenuous , so I will merely point out that anyone with health insurance coverage is having eligibility for various medical treatments determined by accountants, MBA's and a raft of corporate bottom-liners who are more concerned with profit than obtaining quality medical care. When my daughter graduated from college, she could not get health insurance at all, because she had cancer as teen-ager. No insurance provider had the slightest interest in what medical treatment might be most effective for her -- she was merely a statistical risk they wanted to avoid.
You imply -- by the employing the generic term "federal employees" -- that the proposed council would consist of ex-IRS agents, DMV workers and TSA security guards. To the contrary, a committee of highly qualified medical experts would review all the known research on treatment protocols for various illnesses and medical conditions, and determine which treatments, under what conditions, have the best chance of a positive outcome. We know that the corporate medical establishment has a greater concern for the most profit -- hence the marketing of new drugs and procedures which maximize income, not patient outcomes. Insurance companies will often deny care based on cost-benefit statistics related to company profits, not patient need.
I would put my trust in honest, well trained scientists and physicians well before the myriad levels of insurance company bureaucracy that are designed to discourage patient advocacy and reject expensive treatment.
well said
tip jar!!
thank you.
What will be great about government -run health care is that when conservatives are eventually back in power, they can ration treatment toward true victims of disease and away from those whose irresponsible lifestyles have lead to avoidable illnesses like obesity, sirosis from alcohol abuse, lung cancer from smoking and of course aids and other STD's.
Then the rest of us can enjoy then preventative and maintaince care at an affordable rate because all of the aviodable risk has been removed.
this isnt the real howard dean so dont be fooled guys
Dr Reardon overlooks the fact that the health-care industry is the largest employer in the U.S. It produces almost 17 percent of the nation’s gross domestic product. Yet the bill treats health care the way European governments do: as a cost problem instead of a growth industry. Imagine limiting growth and innovation in the electronics or auto industry during this downturn. This stimulus is dangerous to your health and the economy.
Also, the Federal Council Senor Axelrod and Dr Reardon refer to is modeled after a U.K. board discussed in Sen. Daschle’s book. This board approves or rejects treatments using a formula that divides the cost of the treatment by the number of years the patient is likely to benefit. Treatments for younger patients are more often approved than treatments for diseases that affect the elderly, such as osteoporosis. So tell your parents to keep in good health.
In 2006, a U.K. health board decreed that elderly patients with macular degeneration had to wait until they went blind in one eye before they could get a costly new drug to save the other eye. It took almost three years of public protests before the board reversed its decision.
If the Obama administration’s economic stimulus bill passes the Senate in its current form, seniors in the U.S. will face similar rationing. Defenders of the system say that individuals benefit in younger years and sacrifice later.
True. And I am the first to say that the UK NHS is not perfect, but NO ONE loses their life savings or goes into bankruptcy due to an unexpected illness. We could go on and on with one anecdote after another, but the UK system is infinitely better than what we have in the US. The UK system's "bottom line" is not driven by stockholders, it's driven by pragmatism: how many people can be helped given the funds available. .
The 45 million without health care claim is completely overblown. If you really crunch the numbers, it is more like 8 million.
Here's the problem with health care today. In my former job, I worked for a small firm here in town. My health care was a POS plan through Carefirst. I was paying nearly $800 a month for healthcare which is outrageous. Here are some of the problems with that figure. The $800 a month represents about 40% of the overall cost which my former employer picked up the other 60%. 32% of the $800 figure at Carefirst goes to deal with administrative costs, mainly regulations.
The other problem with health care in America today? my company which is based in VA can't get an out of state quote on health care say in Oklahoma. What I paid is based on the average male in VA. Say the companies in the U.S. were allowed to go outside its borders and get health rates based in another state, maybe across the country? Say the rate was $200 a month based out of Okla? That would bring rates down and make the current system more affordable But the Government won't do that.
They want to create a whole other bureaucracy to redo Health Care. We have Medicare already, but Medicare is so far in the hole, when the Feds bailout Medicare it is going to make this current situation look like a joke.
If the government had not raped the Medicare/Social Security programs it wouldn't now be looking for ways to lower the cost of health care (which by the way is already bought and paid for after years of payroll deductions) for seniors.
I am beginning to believe, increasingly, that concern for the 'cost' of health care is a red herring entirely. Insurance companies are concerned with making a profit, with sharing the cost as widely as possible and delivering as little actual service as possible for the money received. That is how one makes money in the insurance business, by selling insurance and not paying out. Likewise government concerns about health costs are politically motivated, whether concern for the cost to the individual or the concern for the cost to the government/taxpayers.
I think that for the system to really meet the needs of the nation, truly radical reform is necessary. I think truly radical reform will require the elimination of 'cost' as a factor in the debate. While I can make many economic arguments for why single payer government health care, for instance, would cost everyone less than the current system, the cost is not the real problem of the debate.
The real issue is the existence of an industry that makes a great deal of money, employs quite a few people, and wishes to protect its own existence. 'Cost' is simply a tool in its efforts to do so.
I don't think government bureaucrats should make medical decisions anymore than insurance bureaucrats and consider the change from one to the other relatively meaningless. I would prefer to see doctors and patients making decisions based on medical need.
cut out the health insurance companies. let the government be the only health insurance provider, like in the UK. everyone pays the same rate according to what and how you earn, and if you get sick you get treatment. simple. no forms, or insurance companies or nothing.
americans need to demand this. no one should be denied health treatment because they have been ill in the past or have a current disease. its wrong.
That's right: the minimum wage clerks at the insurance companies should do the deciding. with the goal of not paying claims.
I'd rather that truly scientific studies [even those conducted by the government] decide what works and what doesn't.
I'm retired, so I have time on my hands. Next time YOUR child needs care LET ME decide whether it is appropriate. After all I don't work for the government, and at least I'm not trying to save your employers money.
I have what passes for good health INSURANCE. But it costs. Let's not fog this issue. What most people really want is good health care. They do not particularly want an insurance company, with high overhead due to excessive executive salaries and large staffs of people deciding what coverage is ok (and denying a lot of procedures). These for profit companies do stand between people and their physicians not and cost an excessive amount. Why complain that the government will do that except to protect the excessive profits? The system couldn't be any worse.
Besides, what this is about is information. Good information is needed for a free market, remember? Doctors need good information to decide about treatment, remember? I remember Newt G saying people wanted choice. Fine. That requires very good information. The more the better and it won't come from the companies.
Dr. Reardon,I always respect your opinions. One of my concerns is that the Republicans have framed this debate as being "taking the medical decisions from the Doctors to the Gpovernment". What I think the debate is "taking control from Insurance Companies,that have abused the system and restructure it at the Government level"
30 Plus yrs ago when I was in x-ray Insurance Companies outlined DRG payments. Essentially saying what they would pay hospitals for X problem. The incetive was to get you in and out fast. Then they had hospital consortium buying groups to make hospitals profitabe and buy out Doctor's practices and control their productivity. Then They increase premiums,cut back on approvals,deny care for pre existing conditions or some other reason like it does not fit their protocol. As far as I understand this problem Insurance companies are deciding who gets what based on their rules. THIS MUST CHANGE.
See Kathleen Reardon's Profile
Igillooly: I couldn't agree more on the need for extraordinary change. But, and you may agree, I don't think we should allow Republican framing tactics to keep us from making sure what is done to improve health care is done well. We shouldn't stop observing and commenting just because Republicans might have a talking point into which people who think in either-or categories might place our thoughts. I know that's not what you meant as I can see that you are not an either-or thinker. I appreciate your thoughtful response. What we need is the ability to have dialogue and debate without worrying whether a few vocal Republicans are somehow going to twist our words into what they prefer. That's a trap born of fear. And it leads to doing things wrong. We need to bring an end to what you describe, achieve that change, and do so with our heads on straight -- with intelligence, insight and empathy. Urgency can co-exist with caution. We'd be going in with our eyes open. Thanks.
Ms. Reardon,
Thank you for your response. I would love to see the Doctors and caregivers be the people who call the shots concerning our care. I believe that has not been the case for many yrs. Insurance and Pharma Companies spend millions on Lobbyists and millions on denying care. So much $ is wasted in this system while our Healthcare deteriorates as compared to other industrialized Countries. Yes, we have some of the best facilities and Doctors in the World,but overall care has decreased and quality decreased while costs have gone through the roof.(16 percent of GDP or more)
Should it be such a "for profit" endeavor? I believe in free markets and capitolism,but when the bottom line becomes more important than the care something must change.
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