Health care reform and primary sources

One thing I always encourage my residents and students to do is to go to primary sources.  If someone tells you that thiazide diruetics should be the first line treatment for hypertension, get on MedLine and see if that assertion is congruent with the evidence.  It’s important to see how we arrive at broad treatment recommendations, how strong and consistent the evidence is, and the best way to do this is go back to the beginning.

This is not an explicitly political blog, and for that reason, I don’t feel it’s appropriate for me to advocate for one or another proposed health care reform plan.  But I do want to encourage everyone to follow health care reform closely, and to go to the primary sources. Certain aspects of the proposed bill will be hard for any of us to understand, especially cost.  There are all sorts of wild claims about how much reform will save us or cost us, and I’m betting that none of these claims is completely congruent with the truth.  But some of  what we’re hearing on the news is so far from the truth that to call them lies would be generous.

Some people are spouting outright fear-mongering propaganda regarding health care reform, and in medicine, propaganda is the enemy of good decision-making.  Whether you are personally conservative, liberal, libertarian, or none of the above, you can’t have an informed opinion about health care reform without going to the primary source, the actual text of the bill.  If you listen to the pundits, they make it sound as if this bill is so impossibly long that no mere mortal can read it—this is not true.  The bill contains a lot of mundane information regarding definitions, etc., as it is a law that must be implemented, but the information about health care is pretty clear.

In this space we’ll examine some of the more fanciful—non-economic–claims made about the proposed health care plan, using the text of HR 3200 (linked above) as a guide.

Comparative effectiveness or Soylent Green?

The Wall Street Journal published an OpEd piece claiming that provisions providing for comparative effectiveness research amount to a system for denying senior citizens life-sustaining care.  It claimed, specifically:

The assault against seniors began with the stimulus package in February. Slipped into the bill was substantial funding for comparative effectiveness research, which is generally code for limiting care based on the patient’s age.

This is poppycock.  “Comparative effectiveness” is an au courant term used to describe research that looks at medical practice and tries to assess its effects. For example, there are two surgical ways to fix blood flow to the heart muscle: percutaneous coronary interventions (PCIs) such as angioplasty and stenting, and coronary artery bypass grafting (CABG or “heart bypass”). I’m not going to tell you which one is better, because the answer is complicated and still being investigated, but to choose the correct therapy for a patient we must answer a number of questions: which works best in which kind of patient; how long does each last; which has lower complication rates; which leads to longer survival; which leads to longer survival without additional need for a second intervention; which costs more, and over what time period; which makes people feel and function better. These questions and others need to be asked about many of the things we do, and comparative effectiveness research is a reasonable way to approach this.

What does the actual bill say about comparative effectiveness?  Quite a  bit actually, but we’ll look at just a little.

‘(2) DISSEMINATION PROTOCOLS AND STRATEGIES- The Center shall develop protocols and strategies for the appropriate dissemination of research findings in order to ensure effective communication of findings and the use and incorporation of such findings into relevant activities for the purpose of informing higher quality and more effective and efficient decisions regarding medical items and services. In developing and adopting such protocols and strategies, the Center shall consult with stakeholders concerning the types of dissemination that will be most useful to the end users of information and may provide for the utilization of multiple formats for conveying findings to different audiences, including dissemination to individuals with limited English proficiency.

The bill sets up a commission, and sets out all of the details about how it will be constructed, funded, etc.  It does not in any way mandate, recommend, or approve of withholding care from people who need it.  To continue to inject honesty here, there are real implications to this stuff.  If we find, for instance, that getting MRIs on people with less than six weeks of knee pain does not affect the course of their injury, then there could be specific incentives and mandates to avoid these studies.  This will affect people who own MRIs.  This will affect the way doctors practice.  This may impinge on patient “choice”.  But it does not require us to “pull the plug” on old folks.

Logan’s Run

Another common myth circulating is that the bill would require doctors to counsel old folks on euthanasia.  This is patently absurd, and an intentional misreading of the bill. Here is the relevant excerpt:

..the term `advance care planning consultation’ means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation within the last 5 years. Such consultation shall include the following:`(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to.

`(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses.

`(C) An explanation by the practitioner of the role and responsibilities of a health care proxy.

`(D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act of 1965).

`(E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title.

`(F)(i) Subject to clause (ii), an explanation of orders regarding life sustaining treatment or similar orders, which shall include–

`(I) the reasons why the development of such an order is beneficial to the individual and the individual’s family and the reasons why such an order should be updated periodically as the health of the individual changes;

`(II) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and

`(III) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decisionmaker (also known as a health care proxy).

I already provide my patients with counseling regarding advanced directives, end of life care, home care, nursing home care, etc.,  but I can’t get paid for it. What the proposed bill would do is make it easier for me to talk to patients once in a while by actually paying me for my time and expertise. I’ve bolded some of the key points above. To think there is anything sinister about this is to be completely ignorant of the problems older people deal with every day.

Absurdist dystopia

Ex-governor Sarah Palin of Alaska has perhaps the wildest claim:

And who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course. The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether they are worthy of health care. Such a system is downright evil.

Health care reform is going to affect all of us, and the only way to have a rational discussion and to come to some agreement as a nation is to work from facts.  The bill isn’t written in some impenetrable gibberish: it’s fairly plain English.  If you hear wild claims, go to the text to see if it bears them out.  Remember than everyone—everyone—has a stake in this, beneficent, sinister, or neutral.  Judge, write, speak out, but do so as an informed citizen.  In science-based medicine, propaganda is the enemy, truth the most important tool.

Posted in: Politics and Regulation, Science and Medicine

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12 thoughts on “Health care reform and primary sources

  1. Ed Whitney says:

    Sarah Palin is afraid that children with Down syndrome will be denied care by non-existent Obama death panels if health insurance is nationalized.

    Down syndrome is a “pre-existing” condition under the system of private insurance which she supports. Coverage for services may be a problem when the insurance company bureaucrats in Connecticut (who may earn a bonus if they can figure out how to deny a claim) make decisions about care.

    Serious policy discussions are not for clowns.

  2. LionDancer says:

    I wish that it was as simple as going to the original source. The screamers that are making the headlines have been very riled up in an emotional way so that they will scream and make headlines.
    I suggest that all people that are for a rational and measured discussion of the merits of health care reform (I’m purposely not taking a position on health care reform here) come together at these media fests and do a group face palm at the yellers in the crowd.

    Someone should hold their right hand high above their heads for a count of 3 and shout “FACEPALM”. After this all who are for a return to rationality should do an exaggerated face, perferably with a harmonic groan traveling through the crowd.

    Maybe then the rational will get some ink (or electrons).

    Together now

    FACEPALMing for rationality.

  3. Michelle B says:

    My husband and I have tried reading the original source in this case and gave up. With your insistence ringing in our ears, we tried again and are close to giving up yet again. There are several references to other codes and bills, of which are not attached. The language is so obtuse and jargon ridden, it is hard not to lose the meaning of any paragraph. There is no excuse that a scriptwriter who is both a politician and lawyer has not written a concise summary for all to read.

    This bill has certain exemptions for religious denominations–we can imagine the folks who do not want to have any health care coverage will suddenly have to become religious in order to keep themselves in a health-care-covered free state (and yes, there are individuals with very good reasons why it is better for them to have no health insurance).

    Anyways, as with all laws, there are a tremendous number of loopholes. Though the French system (the one we are under) provides excellent health care, the execution and management of the system is full of loopholes and confusion and layer upon layer of management. In our tortured reading of the proposed American plan, it seems that the management of the American version will be even more contorted and difficult to pull off without waste as the French system is. It would be great if people were dispassionate enough to learn from the pros and cons of other existing health care systems so a newer model will be the best, gleaned and fashioned from all the mistakes the older ones present.

    I adore the facepalming for rationality idea, LionDancer!

  4. weing says:

    I think Congress is really screwing this up. We really do need health care reform. They could have just opened up the benefits package that they have to the rest of the country to come on board. Instead, they are trying to institute a two tier system. One for themselves and one for the hoi polloi.

  5. Newcoaster says:

    As an interested Canadian observer of American politics, I really do hope Americans can put aside partisan politics and get this thing done.

    The blatant lies, scare tactics and fear-mongering of the extreme right wing are sickening to watch, and remind me of the lead up to the invasion of Iraq.

    Americans need some form of single payer system, and it doesn’t have to resemble any of the other versions used by different countries, but can take the best of them, and drop what doesn’t work.

  6. weing says:

    The extreme left wing is no better.

  7. TsuDhoNimh says:

    You mean Obama isn’t out to KILL me?

    I’m so relieved.

  8. wertys says:


    We need a system like the catholic ‘offering up’ belief, whereby my excess of FACEPALMing can be offered up to help others who can’t or won’t FACEPALM for themselves !

    I support FACEPALM for rationality

  9. Basiorana says:

    The best part of Palin’s comment?

    Under the current system, BECAUSE private insurance will almost never accept a Down’s child (who have very high costs of care with their many health problems- it’s not even that the companies are stingy, it’s that paying for them in any kind of group-payer plan would mean insane, astronomical costs for all the others in the group), almost all Down’s children are covered under state aid. In fact, her own son will likely be on a Medicaid/are program very soon, once the state plan that covers her family as the Governor no longer covers him. I have never known a Down’s child or adult who was able to have any health coverage that was not socialized.

    So in other words, to her, the socialized state plan her kid will be on now is somehow magically worse than the socialized state plan he would be on were this to pass?

  10. yeahsurewhatever says:

    I’m not going to specifically weigh in on this issue except to say that more law never solved any problem in history, whatever the shortcomings of the status quo might be.

    Introducing a new system, in really real reality, is going to result in approximately 2 decades of substandard care just because nobody knows how anything works anymore.

  11. idoubtit says:

    # yeahsurewhateveron wrote:
    I’m not going to specifically weigh in on this issue except to say that more law never solved any problem in history, whatever the shortcomings of the status quo might be.

    Sorry, this makes no sense. We have laws because some people think they are entitled to do whatever the hell they want. If we didn’t enact laws, you would have a country whose air, water and land are more decimated by pollution, for one example. Industry would not play nice without the threat of being put under. They whine and complain about every law – it will put them out of business. I can give you several example for coal mining alone.

    I’m not saying laws are perfect but they do have value. However, as a regulation writer the language is tortuous and there are too many laws that are stupid and pointless. But, thanks to lawyers and our litigious citizenry often trying to avoid what most of us would deem a reasonable responsibility, they are what they are. So, criticizing more laws is a shear drop off for the discussion.

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