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Health Policy

The End of an Era

May 29, 2012

It’s the end of an era in modern medicine. House is no more.

The Fox show House ended last week. It was entertaining, but as far as health policy is concerned, we’re not sorry to see it go. The main character (Dr. Gregory House, played by Hugh Laurie) exemplifies the kind of “cowboy doctor” too many patients have come to expect. The cowboy doctor rides in on a lab result and offers a brilliant diagnosis, saves the patient’s life, and rides off into the sunset, never to be heard from again. It’s the dominant image of heroic doctors in television. Even Hawkeye Pierce, the caring Army surgeon in M*A*S*H whose demeanor is the polar opposite of House, saw his patients in one-off interactions before sending them home or back to the front.

For most of us, though, that’s an entirely unrealistic portrait of medicine. Our interaction with doctors is usually about trying to stay healthy and avoid problems, or managing long-term, chronic diseases like diabetes, heart disease, obesity, cancer. We need doctors who will listen to us, who can explain things clearly, and who we’re comfortable telling our concerns. Chronic disease management makes for lousy TV, but in recent years it has become the dominant kind of problem doctors and patients face day to day.

That's not our only quibble with Dr. House. In addition to being a cowboy, he's not much of a diagnostician. Through the magic of scripted TV he somehow manages to stumble on the treatment that saves the patient, almost by accident. He practices what I call “spaghetti on the wall”  medicine—as in, “throw the spaghetti on the wall and see if it sticks.”  He diagnoses his patients' rare illnesses by throwing treatments at patients and seeing what happens—often causing significant harm in the process. That's just bad medicine, and it isn’t something that doctors should do lightly. To us, House isn't a hero, he's a hazard, a catastrophe waiting to happen. Blinded by his own pain, he's indifferent to the suffering he causes through his reckless, unscientific, non-evidence based treatment decisions.

But there’s one point in House’s favor: he works with a team—and that team actually talks to each other. Unfortunately, that’s as unrealistic as the rest of the show. There are only a few hospitals and medical practices (Virginia Mason, in Seattle, comes to mind, and the Mayo Clinic in Rochester, Minnesota) where communication among providers is very good. In most places, the ball gets dropped between the hospital and primary care doctor and home, or even between different specialists in the same hospital.

Maybe one day TV will produce a more realistic version of medicine, but beware: it won't be the clean-cut single interactions we saw in House, or any of the other medical dramas out there. It'll be messy, and it'll be ambiguous: something a lot more like The Wire than Marcus Welby, M.D.

"What are the benefits?' What are the risks? Are there alternatives?"

May 11, 2012
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Those are the final questions in this article on Yahoo! News, under the title "How Much Medicine Do You Need?" The final quote comes from Rita Redberg, editor of the medical journal Archives of Internal Medicine, and pretty much sums up the questions that people ought to ask themselves when considering treatment. There's a lot more in the article that we're not going to summarize--check it out!

The Lifesaving(?) Technology of Facebook

May 10, 2012
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When most of us think about Facebook, the first phrase that comes to mind probably isn’t “good Samaritan.”  Facebook is an easy way to keep in touch with friends, and it can be a gigantic time-suck, for sure, but last week the site did something that could truly benefit a lot of people. On May 1, Facebook launched an initiative to encourage users to become organ donors, and within 24 hours there had been a spike in the number of people volunteering their body parts for the good of others. California’s registry saw almost two months’ worth of people sign up within the first day after the Facebook put up the feature.

Organ transplantation is one of the miracles of modern medicine, but there simply aren’t enough organs to go around for all the patients who need them. According to the United Network for Organ Sharing (UNOS), there are 72,900 people on active lists waiting for an organ. Compare that number to the 2,263 transplants that took place between January 2011 - 2012. Last year, more than 6,000 people died waiting for an organ.Obviously, increasing the number of organ donors could have a huge impact on the number of transplants – and on the lives of thousands of people.

Why don’t more people become donors? Some object on religious grounds, but the biggest obstacle is inertia. Most of us who sign up to be organ donors (I’m one of them) do so when we renew our driver’s license, by checking a box on a form saying we want to donate our organs. If you don’t mark the form, it’s assumed you don’t want to donate. Most people only encounter this choice every few years, when their driver’s license is up for renewal, and it’s hard to think about such a decision while standing at a Department of Motor Vehicles counter.

Some countries, such as Spain, Australia and Germany, have opt-out systems. It’s assumed that you are willing to donate unless you’ve said you prefer not to. Rates of donation in those countries are sometimes higher than in the US, although some presumed-consent countries have much lower rates. (Factors other than the number of donors, like the availability of surgical facilities and transplant surgeons, can affect the number of actual transplants in different countries.)

Another way to get more people to donate would be a “mandated choice.” This idea was proposed by behavioral economist Richard Thaler, in his book Nudge: Improving Decisions About Health, Wealth, and Happiness (with Cass Sunstein). Instead of a form that you can simply leave empty if you don’t know whether you want to donate, you have to choose between “yes” and “no.” There’s psychological evidence that even having to make that choice could get more people to think about their preferences and choose to donate. Israel has yet another incentive to get people to donate: those who are registered as donors get priority if they later need an organ themselves. Facebook’s effort depends on another psychological effect, the power of social persuasion. If your friends are all donors, maybe you should sign up, too.

Whether or not Facebook’s initiative will have a sustained effect on the number of available organs remains to be seen, but there’s a side to this issue that deserves at least a mention. Organ transplants are expensive. The surgery itself can cost as much as a million dollars, and that’s not including the drugs and other care transplant patients require for the rest of their lives. Granted, that’s money well spent in terms of lives saved. But imagine if there were enough organs for every person who needed one. We’d have to find more than $100 billion a year in addition to what we’re already paying for health care.

I’m not suggesting more organ donation is a bad idea, or that we shouldn’t do more transplants. Just the opposite. It would be money well spent. It’s also yet another reason to weed out the trillions of dollars we are on track to waste over the next decade on health care that doesn’t help patients or improve lives.

The Doctor Will See You-If You're Quick

  • By
  • Shannon Brownlee,
  • New America Foundation
April 17, 2012 |

Four years ago a 38-year-old adjunct professor at American University named Fred Holliday began suffering from a variety of ailments: he was losing weight, his blood pressure went up. Then he cracked a rib. And he started suffering from debilitating back pain. Each time a new problem arose, the Washington, D.C., resident visited his doctor, who dealt with his symptoms piecemeal. First she prescribed blood-pressure medication. At another visit, she chalked up his fractured rib to violent coughing from a cold he had. Then she prescribed narcotics for his back.

Why Doctors Uselessly Prescribe Antibiotics for a Common Cold

  • By
  • Shannon Brownlee,
  • New America Foundation
April 16, 2012 |

Last week, nine physician specialty societies announced a list of 45 treatments and tests that doctors should prescribe far less often or stop doing entirely. Each specialty society’s list is part of the American Board of Internal Medicine’s Choosing Wisely campaign, a long overdue initiative intended to get physicians to think twice before giving patients tests, drugs and other treatments that aren’t going to help the doctor diagnose the problem or help the patient get better.

A Belated SCOTUS Wrap-up, and A Look Forward

April 13, 2012
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Unless you've been living under a whole pile of rocks, you heard about the Supreme Court’s oral arguments in Florida v. Department of Health and Human Services—the Obamacare case. You’ve probably heard by now from a dozen reporters and pundits who claim that they know which way the Court will rule.

I’m not going to make that claim. There are understandable arguments on both sides, and it’s incredibly difficult to predict how this Court will decide on such an important, divisive, politically charged issue.

Instead, I want to provide a little perspective. Even if the Court decides that the individual mandate is not a Constitutional exercise of Congressional power, the consensus of Courtwatchers is that they’re unlikely to toss the entire law down the drain with it. If the mandate is unconstitutional, there are two main options without throwing out the whole thing: the mandate might get thrown out on its own, or two crucial insurance reforms (community rating and guaranteed issue) might go with it.

Guaranteed issue and community rating are the key pieces of the law—they require insurers to give insurance to anyone who comes asking, and limit the amount that prices can vary between people, respectively. The individual mandate was designed by the Heritage Foundation during the last health care debate (over President Clinton’s health care reforms, in 1993), and it's designed to attack two economic problems that can emerge when people have that protection: moral hazard and the insurance “death spiral.” Moral hazard is the economics term for the danger that healthy people might go without insurance, only to buy it (at the low, community-rated price) if they get sick. If people can do that, insurance costs have to be higher for responsible buyers who get in at the beginning. The “death spiral” is a similar phenomenon, where people who buy insurance are sicker than average, which drives up the price of insurance. That price increase makes more healthy people drop their coverage, leading to an even sicker risk pool and higher costs. Eventually, the insurance market falls apart because the only people left wanting to buy insurance are too sick to afford their own health care costs.

The mandate works by pushing healthy people to buy insurance even when they’re likely to stay healthy—thereby preventing moral hazard, and avoiding death spirals. The thing is, any policy mechanism that makes going without insurance less appealing will work the same way. That means even if Congress isn’t allowed to create an individual mandate, there are a whole slew of other options for what they could do. Several mechanisms have been proposed that would achieve exactly the same result as the mandate penalty, but would do it through the tax code, where Congressional power is less restricted. Those might still be challenged in court, but would have a better chance of survival. Alternatively, Congress could just force people who choose to go without insurance to stay that way, even if they get sick: it would be entirely within Congress’s power to say that an individual who could have gotten insurance and didn’t, would: 1) not be eligible for insurance subsidies if he wanted to get insurance on the exchanges; 2) not have guaranteed coverage for any pre-existing condition; 3) not be protected by guaranteed issue and community rating, so he might have to pay an incredibly high premium if he could get insurance at all. Those penalties might be in effect for five years from the date when he declined insurance, in order to strongly discourage people from making rash choices because they feel healthy this month.

That would, in effect, create a universal insurance system, with an opt-out for the very confident and those who genuinely wish to self-insure. It would be indisputably within Congress’s Commerce Clause power, too—it would be a direct regulation of insurers and participants in the insurance market. If the mandate gets struck down, it would be a relatively simple legislative task (although perhaps a heavy political lift) to fix the law and restore its universality.

As an eternal reminder: the Affordable Care Act didn’t fix the American health care system—it aimed only at the health insurance system. Researchers have documented unnecessary care that costs hundreds of billions of dollars each year, and the law does little to attack that waste. Correcting the delivery system will require hard political and practical conversations about global budgets, evidence-based care, and getting control of the outrageous growth in health care resources. Depending on how the Court rules, health care might fall off the political radar this year, but you can be sure it’ll be back soon enough. The system has too much waste—and too much opportunity for improvement—to let it go when the Justices rule.

Unnecessary Care on the Diane Rehm Show

April 9, 2012
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If you missed the broadcast (and our live-tweeting!) this morning, be sure to check out the great discussion of Choosing Wisely, unnecessary care, and what patients and providers can do about it on the Diane Rehm show this morning! The panel included our program director, Shannon Brownlee, Dr Christine Cassel of the ABIM Foundation, Dr. Eric Topol of Scripps Health, and Dr. Ranit Mishori of the Georgetown University School of Medicine.

The panel was well-informed and willing to admit the strengths and weaknesses of the Choosing Wisely program. They all agreed that patients can't fix overtreatment on their own--doctors have to take responsibility for making evidence-based recommendations, and for considering whether test results have any real clinical consequences. In cases where a test doesn't provide any useful or consequential information, the responsible thing to do is skip the test. They also agreed that the problem goes beyond fear of malpractice lawsuits--overtreatment and unnecessary care comes from a culture of "more medical care is better," and the financial incentives that go along with that assumption.

There's a lot more in the program: check it out! And don't forget to look at the website for the Avoiding Avoidable Care conference, coming up later this month!

An Introduction!

April 9, 2012
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We’re happy to introduce our new Spring Intern, Chris Hildebrand, who will be blogging for us regularly until he graduates from his Master of Public Policy program at Georgetown University’s Public Policy Institute.

Chris got his BA from Grinnell College in 2010, where he studied Political Science, before moving to Washington to pursue his MPP at Georgetown. Chris has previously interned at the Bipartisan Policy Center, where he researched the debt ceiling and focused on major budgetary issues for the BPC’s Economic Policy Project.

We’re looking forward to posting his work on the blog, and we hope you enjoy his writing!

A good start, but only a start

April 5, 2012
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Yesterday, the ABIM Foundation's Choosing Wisely initiative released a list of 45 medical procedures in nine specialties that doctors shouldn't use, and that patients should know are not necessary. The procedures include a variety of treatments, screening tests, and diagnostic tests, including: MRI and CT scans for low back pain without red flags; cardiac imaging tests for patients with chest pain and low risk of complications; brain imaging for a simple headache; and curative treatment for cancer patients when there's no reason to think the treatments will work.  All of the recommendations are based on solid medical evidence that the procedures harm patients, provide no benefit, or provide extremely small benefits at very high costs.

It's remarkable that the ABIM Foundation was able to pull together panels of people in all of these specialties (allergy, asthma, and immunology, family medicine, cardiology, general internal medicine, radiology, gastroenterology, clinical oncology,  nephrology, and nuclear cardiology) who were willing to agree that these treatments and tests are not beneficial to patients. It speaks to the strength of the evidence against performing useless treatments.

Dr. Vikas Saini, a cardiologist and president of the Lown Cardiovascular Research Foundation, has more commentary over at his blog:

"The truth is, guidelines and appropriate use criteria are used sparingly in practice. Occasionally, in a tough case. But there is such a guideline explosion, you need a guideline for the guidelines.  I don’t blame practicing clinicians when they ignore them. If we are to tackle this problem seriously, what we need of our doctors needs to be baked into their (our) daily cognitive frames, habits, and attitudes."

Take a look at the whole post--it's definitely worth a read.

We'll certainly be covering this initiative as it continues--there are another eight or more specialty societies preparing lists now, for release this fall,  including hospice and palliative care, geriatrics, and hospital medicine. Be sure to check out the website for the Avoiding Avoidable Care conference, as well (avoidablecare.org)--we'll be talking about a lot of the same issues!

The Right Rx for Better Health Care: Rise Up to Challenge the Industry's Lobbying Power

  • By
  • Shannon Brownlee,
  • New America Foundation
  • and Brian Klepper
March 29, 2012 |

Obamacare had its days in the Supreme Court this week, and the justices’ decision could have sweeping consequences for the individual mandate provision in the Patient Protection and Affordable Care Act, and maybe even for the fate of the law itself.

Yet whatever the court decides, we will still be stuck with a problem that this contentious law was not likely to solve on its own: an out of control health care industry that threatens the stability of the U.S. economy and the federal government’s ability to deal with our long-term debt.

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