Like most others I know, my knowledge base about health care is limited to my own small personal world, so the swelling public discussion is hitting me with an avalanche of information I never heard of, starting last month with a good friend passing along an email scare piece with this Bloomberg piece by Betsy McCaughey.

This is a deliberately negative, misleading attempt to kill affordable universal health care while still in the cradle. The Wall Street Journal last month reported that “The drug and medical-device industries are mobilizing to gut a provision in the stimulus bill that would spend $1.1 billion on research comparing medical treatments, portraying it as the first step to government rationing.” Indeed, Betsy McCaughey, former lieutenant governor of New York, adjunct senior fellow at the Hudson Institute and long-time opponent of universal health care, last week published a damaging hit piece conflating clinical clinical effectiveness research with cost effectiveness in a misleading effort to frighten people with the notion that government is attempting to ration their health care. I’m no big fan of AARP but even there someone saw through it. Ms. McCaughey has a fifteen-year history of fighting universal health care, going back to Hillary Cllinton’s ill-fated attempts.

As this debate unfolds I expect a serious and quite ugly fight to develop as Big Pharma and Big Insurance break out their big guns. Those two powerful interest groups together with Republican politicians who now have little to gain and everything to lose in the midterm elections by being a “loyal opposition” create a perfect storm that can kill off meaningful health care reform for years to come.

I’m leaving this comment a month too late hoping that by now a hidden agenda has been revealed. Many special interests stand in solid opposition to the notion of universal health care and as the debate becomes more public I expect them to begin closing ranks.

http://www.washingtonmonthly.com/archives/individual/2009_02/016884.php

EXPOSING A LIE ON A GRANDER SCALE…. The “award” for the Lie of the Week has some competition, but I have a favorite. Betsy McCaughey, a staffer at a conservative think tank who also used to be a Republican Lt. Gov. of New York, went after the economic stimulus plan on Monday, arguing that it would create a “new bureaucracy” to “monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective.”

None of this is even remotely true, but the claim quickly ricocheted through conservative media outlets.

Part of the problem, though, is that those spreading the lie — Fox News, Rush Limbaugh, et al — have an impressive megaphone and echo chamber. I know several bloggers and online outlets that addressed the issue, but we have a less imposing reach. It was far more likely for the typical American to hear the lie than the truth….

“Anyone who advocates single payer healthcare should have to practice here for one month. And anyone who hasn’t wisened up by the end of that month should spend an additional month as a patient.”

The VA is a perfect little single payer hell of strict guidelines and rationing. It took 6 hrs and multiple permissions to get through the “chain of command” involved in ordering a CT scan after hours. This same imaging can be obtained in a private hospital in about 30 min on Christmas morning. Do you really want a system more similar to the VA?

Also, why do folks assume a rationally self interested doctor working strictly for his own profit would not follow evidence based guidelines? Wouldn’t providing a superior product increase profits as it seems to in every other industry?

Lastly, the AMA is full of statist asshats (note their positions on smoking bans, seatbelt laws, and helmet laws). I (and many other docs I know) would welcome a laissez-faire market in healthcare where my profits were based exclusively on my ability to meet consumer demand.

Hippocrates may soon shrug at this rate…

Not that I don’t appreciate your work…. But, I thought that it has been established that addiction in people, who truly have pain, is very low. Say as high as 3% and as low as .008%, in scientific studies. What has happened is the junky, who comes in and lies about the use of his medication, makes it impossible for the 97% of the people to get treated, who will never have any problem with addiction. The political intervention, between the patients and his doctors, is a big part of the problem. The present state of science is ignoring most of the science already available. People are hurting now and deserve better treatment. But they have to wait until the evidence becomes less squishy to get relief from 24/7 pain?

And when are we going to figure out what objective measures can tell us, exactly, how much pain a person feels? I was under the impression that, even, my vast educational experience does not allow me to feel another person’s pain, thus having an objective measure. That is one part of the problem. So far, there is no way to get information by any other means than subjective measurement, i.e., what the patient tells you the severity of his pain is. So, if you believe that patient and treat him with high dose opiates, you can, still, lose your career. Or even worse, be locked up as a felon.

EBM guidelines have to be applied with judgment and tailored to each individual patient. If you tie physician reimbursement (or worse licensure) to application of guidelines I guarantee that physicians will respond to the incentives. I also am fairly sure that patient outcomes will be no better and perhaps worse.

We started with this small population subset because it’s easily controlled, but the concept, once proven, can be applied to any acute pain patient and, with quite a bit more work, to the chronic pain field as well.

So now one has to wonder how Obama will reconcile his desire to bring personalized medicine to the fore with this apparent desire to clamp down on innovative practices.

Anyway, Michael, please know that there are people like me who are working very hard to bring solid objective measures to the practice of pain medicine. By doing so, the hope is that the practice will become less “squishy” and, therefore, less open to government misinterpretation. Patient-physician trust will be bolstered by the injection (if i may) of objective measures. This way, patients may be less afraid of addiction, physicians may be less afraid to treat, and the Feds will have one less reason to stick their noses where they don’t belong.

Why not? As it stands now, for-profit insurance bureaucracies dictate medical policy to America’s doctors. Is it the fact that private insurers are profit-driven that makes that okay, but since government is politics-driven it’s suddenly bad? Whoever pays the piper calls the tune. As far as I know, there is no broadly backed program that would forbid people from using private money to do whatever medical treatments they want (with the usual caveats regarding medical ethics). The proposals all limit what Federal funds could be used for; if you want to take your hard-earned money and pay for non-EBM, then you are free to do so.

That kind of micromanaging is already the main reason why poor people who suffer from chronic pain can’t find doctors who will treat them.

No, the War on Your Neighbor is the main reason why poor people who suffer from chronic pain have trouble finding doctors who will treat them, not EBM. The risk of legal action from “overprescribing” pain meds is too high, and the numbers of sandbagging junkies is also too high. If drugs for recreation could be legally obtained, then both of these pressures on doctors would cease. But this idea that medicine is best practiced by super-talented doctors shooting from the hip is fantasy fueled by the carefully-cultivated misconception of doctors as mini-supermen. They are not; they are applied scientists, and when they “use their intuition” (i.e. “make shit up”) people get hurt. Even as recent as twenty years ago, the rate of advance in health care science was slow enough that a specialist could reasonable keep up with it. Now, however, there is so much health science being done that it’s too much for a person to keep up with. EBM yields standards of care that can be easily disseminated to doctors who are busy actually treating patients, telling them what science has found to work best. If you want people making shit up to treat you, go to a homeopath.

One new bureaucracy, the National Coordinator of Health Information Technology, will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective.

The National Coordinator of Health Information Technology already exists, and has since 2004. The stimulus bill added a small panel of experts to coordinate information from various agencies into policy recommendations. I find it very amusing how Republicans take to calling a 15-member panel a “federal bureaucracy”, and how readily people follow along with that abuse of the term.

The bill is vague about what sort of penalties will be imposed on doctors who don’t abide by the recommendations, as well defining the minimum threshold of participation in federal programs that would require a doctor to abide by them.

The penalty is pretty simple, and is the same as for current repeated violations of Medicare and Medicaid regs–Medicare and Medicaid will no longer pay you (unless your violations amount to fraud, in which case you are dealt with the same way you would be dealt with for filing fraudulent claims on private insurance). Again, piper->tune; if doctors don’t want to follow Federal regulations (or regulations set up by various private insurers) then they don’t accept their money. If enough affluent people refuse to accept Federal money, then you will end up with a two-tiered system like we do today, with private medicine for the affluent and public medicine for those who can’t afford private medicine. At least in that case, everyone will have access to public medicine, while those who can afford it can still get their private medicine if they want.

Today while I was out running errands, I was bored with my usual XM music channel (XM74, “Bluesville”), so I switched to talk radio on a local AM channel, for about 15 minutes of drive time.

Then about 14 hours later, after working 4-midnight and coming home to check my RSS feed, I find that Radley Balko and Rush Limbaugh were complaining about exactly the same thing, citing similar passages from the same bill.

Whoah. I think I just felt a shift in the cosmos!

What makes you think that the AMA and its members won’t coopt this part of the federal government the way that big telecoms and broadcasters have coopted the FCC?

I mean, if we didn’t have any medicine or technology at all, no one would have to pay for anything. Free healthcare for all

for the plug for chronic pain patients. Now, that I am no longer a pain practitioner, I have developed some pretty severe neuropathic pain, myself. I sort of look forward to possible getting the medical care I can’t pay for now, being permanently unemployed.

But, I don’t know a lot about evidence based medicine, but…

My mother has a dorsal column stimulator that was inserted at , likely a cost of >$15,000-$20,000. It only helps her pain minimally, and only for short periods of time. She gets more relief by lying in bed. But, staying in bed 24 hours a day is not good for her either. It certainly gives one, a hell of, a bad quality of life! Yet, her family doctor is afraid to prescribe opiates. He wants to keep his job and not end up in jail! (And he might be, maybe, a little ignorant about the extremely low rate of addiction in real pain patients taking opiates)

I was wondering if evidence based medicine might actually be a boon for the doctor that would practice control of chronic pain with medications, like opiates, now demonized. That is, instead of failing interventions, as with my mother. Interventional pain medicine is the newest pain fad. But it is real questionable as to how successful it is at really controlling the pain, while at the same time being very costly. It is well known that there is a lot of raw material available in the middle east for making morphine. Too bad, it cannot be diverted for that instead of into the heroin market.

And politics in medicine is just as bad as government politicians, in making sure that the players in the game are well controlled. Barney Frank was said to have suggested doctor shouldn’t make more than $70,000 a year (recent throw away article)! I guess we (doctors) have been paid, way too much, for way too long, because we took up to twenty years out of our lives to get an education! Just so we could practice medicine, in the present medical environment! I see a lot of physician retirements in the next couple of years! I could be wrong. I guess we will just have to wait and see. But, arrogance in every walk of life, seems to result in controlling all kinds of businesses! It has been suggested that nurses and pharmacists could be just as helpful in treating a lot, of run of the mill, illnesses leaving the physicians for the more difficult diagnoses. OOOHHH!!! God forbid, that would ever happen!

Government has been telling us how to run our medical care based on Medicare policies. Some of these policies like Medicare Part D are so overdone that they are useless. Government is directing much of our health care now. All insurance companies follow Medicare guidelines because they are cheaper in many instances.
Health care is a business no doubt about it. I would prefer a phjysician who follows best practice but also uses her (his) gut instinct when needed.

It’s been less than a month and McCain’s response that Obama would basically “be a second Carter administration” seems to be dead on.

For some reason, I’m reminded of one of the last scenes in Saving Private Ryan where the American soldier (Jewish) and the German soldier are locked in hand-to-hand combat. The German dispatches the American slowly with a knife to the heart, soothingly shooshing him to his death.

I don’t think I need to be an expert on EBM to have an opinion about whether or not a federal bureaucracy ought to be dictating medical policy to America’s doctors or, more to the point, to be critical of the fact that what is undoubtedly a controversial health care proposal was slipped into an unrelated economic stimulus bill that the Obama administration is urging Congress to pass with haste, without taking time to go through everything that’s in it.

Not categorically, no. As a condition of lining up at the public-private feeding trough, though? Very possibly. In the real world, doctors are not romantic individualists striving to bring their brilliant care to a grateful world against the barriers of the state. They are members of a cartel that engages in restraint of trade (the AMA) and participants in an industry that runs on government money. Over their history they’ve used their political power to make economic war on pharmacists, midwives and nurse-practitioners.

That’s all true. But there are protectionist elements in every industry. That’s an argument for the government to end the AMA’s monopoly on writing prescriptions, or to relax the law to allow more urgent care centers or low-cost health centers at Walmart. I don’t see how you get from “the AMA is protectionist” to “so we should be okay with the federal government micromanaging our doctors.” I would guess that the AMA will have a big say in who sits on these various blue-ribbon protocol committees.

The federal government has an enormous influence on the federal health care system, to the point where it would be difficult to practice medicine without incurring some benefits from it. I’m not comfortable with a federal bureaucracy second-guessing a doctor’s diagnoses because he accepts some Medicare patients any more than I’d want the government second-guessing my career choices because I took federally-subsidized student loans, or forcing people in public housing to take drug tests.

That kind of micromanaging is already the main reason why poor people who suffer from chronic pain can’t find doctors who will treat them.