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Health care and the Stimulus Plan

In my last post, I told you a little story about using science- and evidence-based medicine to improve health care.    The focus was primarily on preventing an iatrogenic illness, namely intravenous catheter infections.  A researcher came up with a plausible idea for an intervention, studied it, and found it to be successful—the intervention was science-based in that it was proposed based on sound scientific principles; and it is now evidence-based, in that we now know that this intervention prevents infections.

But we don’t really have an easily accessible repository of evidence-based interventions.  Every field has its own standards, its own literature, and its up to each individual practitioner to interpret the data on their own.

There are some data bases, such as the USPSTF which gives data for preventative services, and PIER, a service of the American College of Physicians, which gives information on specific diseases and includes interpretations of evidence.  There’s also the Cochrane Collaborative, which helps evaluate evidence.   But there is no single “go-to” site for these things, and while we follow evidence-based guidelines in much of our care, there are many times when evidence isn’t just hard to find but is actually unavailable.

Give our “evidence gap”, I was heartened to see this story in the New York Times.   The Times reports that the economic stimulus bill will include over a billion dollars to fund research into medical evidence.  This is a good thing, but it’s bound to be controversial.  But I’ve mentioned before that we need to spend money to improve our medical infrastructure, and this could be a step in the right direction.

Much of what we do in medicine is science-based, and much of it has evidence to support it, but some does not.  There are plenty of open questions about how we practice medicine, and in order to deliver safe, quality care, we need answers. One example was explored by Dr. Gorski earlier.  In another example, a recent study in the New England Journal of Medicine compared surgical and non-surgical therapy for arthritis of the knee.  Surgery made logical, scientific sense, but it had never  been carefully compared to non-surgical therapy.  The study showed that conservative therapy, which is cheaper and less invasive, was just as effective as surgery.  This doesn’t mean that surgery will never help, but it is strong evidence that we should treat arthritis of the knee more conservatively. Studies like this aren’t free, but if their results are reliable and repeatable, they may save us a lot of money and possible surgical complications.

So the idea of investing more money into comparing medical treatments makes sense, both scientifically and economically.  Now there’s a lot of predictable objections about this; people are worried about physician autonomy and government interference.

As Congress translated the idea into legislation, it became a lightning rod for pharmaceutical and medical-device lobbyists, who fear the findings will be used by insurers or the government to deny coverage for more expensive treatments and, thus, to ration care.

In addition, Republican lawmakers and conservative commentators complained that the legislation would allow the federal government to intrude in a person’s health care by enforcing clinical guidelines and treatment protocols.

I’m not sure that the legislation says anything about enforcing clinical guidelines, but to be fair, there is some implication along those lines.

And so what?  Right now, my patients’ insurance programs do exactly the same thing—if I prescribe an angiotensin receptor blocker for blood pressure control, I’m going to be asked to justify why I am giving this rather than the cheaper and as-effective ACE-inhibitor.  The answer is usually that the ACE-I caused side-effects, but the question isn’t stupid.  Why should an insurer pay more when an equally effective, cheaper alternative is available?

If we have more evidence to work with, we can continue to make even better decisions regarding care.  It may seem intrusive, but it’s not very different from what we do already.  And honestly, I’d like to know if I’m more likely to get relief of my lumbar radiculopathy from surgery or from conservative therapy.  I will not be offended in the least if my surgeon got a call from my insurer asking if surgery was really my best option, as long as the answer was supported by good evidence.

It rings rather hollow when people protest against gaining more knowledge.  Libertarian types complain that this will inevitably lead to government interference (and it might, and maybe it should) but to ignore the need for evidence is absurd.  We, as physicians and patients, need more knowledge, not less, and we shouldn’t be afraid of where the data lead.  Once we have the data, we can sit down for a good, heated discussion about what to do with it.  But putting our collective heads in the sand is probably not a useful response.

Posted in: Science and Medicine

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14 thoughts on “Health care and the Stimulus Plan

  1. tarran says:

    The difference between an insurance company and the government is that the insurance company won’t throw you in jail over a disagreement regarding treatment regimens.

    Make no mistake, just as with the creation of NCCAM, and financial regulations, you are going to see the process politicized, you will see politicians attempt to manipulate the process for the benefit of certain special interests at the expense of the populace.

    Time and time again, we see government official propose new programs that they claim will have minimum impact or are intended to be purely advisory. In nearly every case, within a few decades, these programs have mutated into the most intrusive forms imaginable.

    The most prescient predictors of the future of government programs apply a simple system of analysis. They examine a program and ask, how can this be abused to benefit the few at the expense of the many. And the recommendations that the managers of this program make will have the effect of making some people very rich, and other people very poor. These rents will attract rent-seekers like garbage attracts flies.

  2. wertys says:

    Again with the rhetoric about abuse of a centralized healthcare system !

    The US needs something like this to be introduced by fiat so that after a few years (in Australia it took less than 10 years) the population are so happy with their healthcare provision that any attempt to politicize or undermine it is electoral suicide.

    There is nothing inevitable about a centralized healthcare system becoming corrupted and ineffective once established. It may be a bit inefficient, but once people get used to the idea that high-quality healthcare that is widely available cannot be run like a normal business, I’m sure the US will enjoy having infant mortality rates that are better than rural China.

  3. MarkH says:

    I think the issue is that we’ve previously seen problems with the implementation of guidelines by insurers that take away physician autonomy and force them to practice “mother may I” medicine that is highly irritating to many professionals – including my mom for instance. The fact is calling a doctor every time a guideline doesn’t fit their patients who they know better than anyone else is going to drive them totally nuts. These calls take time, unreimbursed time, to have your clinical judgement questioned by a pencil-pusher. Often, simply by allowing them to question the doctors decisions they can make certain costly decisions punitive – making the cost to the doctor in time and paperwork so extensive that the use of a needed medication or test becomes limited *cough* PET-CT *cough*.

    Then there are those guidelines that are supposedly evidence based turn out to be largely biased expert opinion. Perhaps the worst example being from the original surviving sepsis campaign and the supposedly high quality evidence for rhAPC – when the entire committee was composed of docs with conflict, at a meeting sponsored by Lilly (the maker of APC). Worse, when the drug wasn’t being prescribed because of it’s enormous cost and questionable efficacy (despite strong recommendations ignored by most ICU docs) Lilly spread rumors through a PR firm that the drug was being stockpiled, docs were chosing who lived and who died due to a shortage, etc. If insurers can figure out a way to limit costs by influencing guidelines or their implementation they will, and then what is the physicians response if they disagree, often for good reasons with that implementation? The risks for politicization are significant, these are in the end, often just expert opinions – admittedly the lowest form of evidence that can be offered according to qoe standards.

    The guidelines, while helpful, are not a substitute for medical judgment for what an individual patient might need. And the idea that in individual cases doctors should be pestered about each and every decision they make would be frankly maddening. The best possible thing is to provide highly dedicated and motivated medical professionals the evidence, form guidelines that summarize what physicians should do in general or in specific populations, and then let them practice medicine in a way that suits the individual needs of their patients.

    People should not be telling doctors what to do, they should be providing them with evidence to decide what is best.

  4. Peter Lipson says:

    I should perhaps make it more clear that I am much in favor of the idea of funding effectiveness studies. I’m also in favor of making clinical, evidence-based guidelines easily available.

    I’m not all that keen on gov’t control of the physician-patient relationship. That being said, there’s a lot of bad doctors out there who practice crappy medicine without regard to evidence? How do we fix that? I don’t know.

  5. tmac57 says:

    The trouble is getting good research in the hands of patients and doctors, and weeding out the bad research. So much of what gets into mainstream media is just so much garbage, yet the general public is not savvy enough to sort it all out. And I have had doctors push meds and treatments that I knew to be suspect as well, but I knew enough to say “no thanks”.

  6. Fifi says:

    Dr Lipsom – “I’m not all that keen on gov’t control of the physician-patient relationship.”

    Is it really about “control”? That seems to be using “health freedom” language that really has little to do with creating professional standards of care and ethical guidelines. I find it a bit sad that even people in the medical profession are starting to absorb and use this terminology that actually distracts from the real issue of professional responsibility to replace it with propagandistic doublespeak borrowed from the most crass political propagandists (not to mention conjuring images from tampon commercials featuring blond white women in white outfits riding white horses on the beach).

    Who should oversee the physician-patient relationship? No one? Only doctors? Only patients/advocates? Or how about corporations? Right now in the US, corporations seem to have more say in what treatments people get than either doctors or patients.

    If real science is being done, not only will this benefit medicine in that it will evaluate some procedures that obviously need to be evaluated (and which may lead us to all kinds of new understandings) but it will also create an environment within medicine that emphasizes evidence-based treatment (making it harder for CAM to sneak in the back door). Sounds like a really good first step in taking this out of the hands of insurance companies if it’s something done by medical scientists and within the hospital/medical context and not by corporate or government beaurocrats.

  7. wertys says:

    Having a central payer does not automatically mean that the doctors are reduced to menial slave status. Under the Australian Medicare system, a schedule of fees is set which serves as the basis for ongoing fee-for-service funding. The doctors set their own fees, and the patient or a private insurer pays the difference. Public hospitals are funded by the Commonwealth and States jointly, and administered by the States, so no one body or individual can directly control what people are paid or what is paid for. The Australian Medical Association has had a fractious relationship with the Federal Health Minister at times, but to date has been able to keep a high level of Govt scrutiny out of the dr/pt relationship, and as I said previously, if the people of the country make it crystal clear to both sides of politics that it will never be tolerated, then a working arrangement can be struck. Cultural differences between Australia and the US seem to me to be particularly notable on issues like gun control and health care, but very similar in many other ways. Surely there is a way for the richest and most technologically advanced country on earth to figure this stuff out !

  8. Fifi says:

    In Canada, doctors are free to prescribe the treatment they consider best treatment. True, some expensive and not yet proven medications and treatments aren’t covered under medicare (but Americans get denied needed treatment by their insurers all the time). And, yes, our system has been under attack by corporate lobbyists who have tried againa and again to dismantle public healthcare to appease corporate employers and pals (such as our current PM Stephen Harper, who is loyal to the same advisers as President Bush Jr was, and was a paid lobbyist for private healthcare).

    However, particularly with the economy tanking, the US will run into the same issues with doctor shortages and aging populations as Canada and the US. One reason why SCAM has such traction in the US is because healthcare isn’t about pragmatism but about profit. Ultimately, medicine has to be pretty damn pragmatic to be of any use at all since it’s not about ideology but biology.

  9. Lame-R says:

    wertys, you should become more familiar with the Australian healthcare system before you hold it up for comparison.

    From the Australian Health Care Reform Alliance, a very short summary:

    “The key problems with the health system are:

    · the health gap between Indigenous and non-Indigenous Australians

    · many Australians cannot access health care when and where they need it

    · a chronic shortage of doctors, nurses and other health professionals

    · insufficient focus on prevention and primary care

    · the inefficient allocation of resources caused by the current State/ Commonwealth funding structure.”

  10. Fifi says:

    Australia’s healthcare system is a compromise between private and public healthcare at this point, it’s not just public healthcare in the same sense as it is in Canada. This isn’t a criticism, it’s just what it is.

    - the health gap between indigenous people and non-indigenous people are similar all over the world. (Canada is particularly appallling but many American reservations are awful too.) This is due to racism and marginalization of communities and not the type of healthcare system.

    -many Americans cannot access healthcare when and where they need it (even those who have private insurance may be refused best treatment). When it cost $5, 000 to get a simple broken arm set, healthcare is hardly “accessible”.

    -There’s an chronic international shortage of doctors, nurses and health professionals (including in the US, Canadian nurses get offered huge amounts to work in the US). This is largely due to the bulge in the aging population that’s then combined with both older doctors retiring and a smaller pool of younger doctors who aren’t willing to work the insane hours their elders often did. (There are also issues regarding quotas at medical schools and exclusionary immigration policies that prevent immgrant health professionals from entering the system that played into the current shortage in Canada, I’m not sure about in Australia.) Nursing isn’t a particularly attractive profession these days, now that women have other employment options and one can make much more and work better hours in other professions that require the same amount of training.

    -there’s insufficient focus on prevention and primary care in the US too (Canada has some programs but they could be much stronger).

    The big issues and challenges facing healthcare providers in countries like the US, Canada and Australia have more to do with poor planning and shortsightedness regarding aging boomers than anything else. It’s not like any system is actually handling these issue – or even directly facing them – better than the other!

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