Convergence and Divergence of Health and Health Care

As I participated in the Hope Street Group project to Re-Invent Primary Care, I came to think about how medicine is at a unique opportunity to both converge and diverge at the same time. This creates some tension as different stakeholders favor going in opposing directions. However, I think there is a framework that will enable us to strive for a healthier society. To do so, we should recognize that "health care" is really two things: 1) maintaining health and 2) treating illness.

Maintaining health should be primarily the responsibility of patients and communities. Physicians are, let's be honest here, not really trained to think about maintaining and promoting health and healthy behaviors. These behaviors should be taught in school, supported by the design of communities, and re-enforced by cultural ideals. The health care system (clinics, hospitals, etc) is not the ideal place to instill such education about health. It would be best to decentralize the way we promote health and healthy behaviors. Instead, these should be "outsourced" to families and communities in order to create a culture of health. As a society, we should emphasize that maintaining health is the responsibility of patients.

How? Tough question, for sure. But social and personal media can help -- just think if your cell phone kept track of how far you walked every day, or if your grocery discount card also provided feedback on your diet (in comparison to ideals and other people). This is a realm of huge potential for innovation, particularly if patients/consumers know it is their responsibility to find the tools that work for them.

This is the divergence -- maintaining health as the responsibility of the individual and community. There will be roles for policy changes related to food subsidies, zoning codes for fast food, etc, but the bulk of the power still lies with the individual (which can be encouraged through social interactions).

The opposing tension is the "sick care" system: how we treat individuals when they do become ill. Appendicitis will still happen, as will infections and heart attacks. When they do happen, patients should be treated in integrated, comprehensive care systems that know their past medical history, have a full range of treatment options available (acute primary care appointments all the way up to the ICU and cardiac surgery). When people develop acute illnesses, our system should be consolidated and coordinated to care for them.

This means the era of the solo practice - the "cowboy physician" - is coming to an end. Physicians are more likely to be leading health care teams that care for patients, seeing the patients when needed due to acute illnesses or complex cases, but coordinating care with nurse practicianers when able and appropriate.

We need an integrated, vertical health care system that can treat everything from a minor ailment to highly complex illnesses. This will require consolidation of the health care system, but not every patient and every appointment will need to be seen at a major academic institution. There is still a role for the local provider, but that provider should be connected to (no, integrated with) secondary and tertiary care centers that can pick up the care of patients that exceeds the capacity of the local provider.

So, that's how I see the future of medicine: empowering individuals with the tools and instilling them with the sense of responsibility to maintain their health, while integrating and consolidating the treatment of acute illnesses into multi-specialty health care organizations when they do occur.


My comments to the FDA advisory committee re: rosiglitazone

Thank you to the committee for taking the time to listen to our testimony today. My name is Dr. Christopher McCoy. I am the chair of the Policy Committee of the National Physicians Alliance, a national multi-specialty organization of physicians committed to restoring the integrity of our profession. The National Physicians Alliance does not accept funding from pharmaceutical or device manufacturers; I have no personal financial disclosures. I am Board-certified in internal medicine, and practice as a hospitalist at the Mayo Clinic in Rochester, Minnesota. I speak today on behalf of myself, my patients and the National Physicians Alliance. I do not represent the views of the Mayo Clinic.

I would like to make three points today:
• First and foremost, the FDA is charged with ensuring that prescription medications are safe and effective; patients and physicians must have trust in the treatments that are prescribed.
• Secondly, healthy skepticism and a thorough analysis of the all data is fundamental to advancing the science of medicine.
• Lastly, evidence has repeatedly shown that financial relationships with the pharmaceutical industry correlate with endorsement of the industries' products; furthermore, it is likely that the pharmaceutical industry amplifies the voices and views that favor its perspective.

As a physician, I make recommendations to my patients about the best treatments available. When questions are raised about the safety of medications, the public and providers look to the FDA for guidance. As a practicing physician, I do not have the time nor the expertise required to fully critique all of the complex studies that have raised concerns about the safety of rosiglitazone. Moreover, providers and patients do not have - as the FDA does - access to the original data to re-analyze and confirm the stated findings. We understand that prescription drugs have associated harms and must be used judiciously, but to fulfill my role as a physician, I need to know the extent of the risks of the medications I prescribe. To do that, we trust that FDA is fulfilling its duty to ensure that our pharmaceuticals are both safe and effective.

The episode with rosiglitazone is unfortunately not uncommon: a new medication is approved for use, it is widely promoted by the manufacturer, and then new safety concerns slowly become apparent as more data are collected. A healthy scientific process requires an active discussion about new data and conducting further studies to confirm trends. But the FDA should also determine when we reach a point when additional studies are merely delaying the inevitable and a definitive answer can be based in the existing evidence.

On my final point, a multitude of peer-reviewed articles has shown that individuals with financial ties to industry are more likely to provide perspectives that support the industry. In a review of published articles about rosiglitazone since the original Nissen article, my colleagues and I found that 66% of the authors with financial ties to the manufacturer expressed favorable opinions of the medication, while only 8% of those without financial ties were of the same opinion. This is not to imply that physicians and scientists can be "bought" by industry, but it raises the concern that the industry amplifies the voices and views of those who provide the perspective that industry wishes to promote. However, the scientific process is not a weighing of all perspectives and a pursuit of a compromise. Science search for a definitive answer to a question. Today that question is: Does rosiglitazone clearly and unambiguously meet the standards of safe and effective?

In summary, we have all pledged, “First, do no harm”. That first principle of medicine is the core of the discussing today. As a physician, I rely on the FDA to closely and thoroughly review the data regarding the safety of prescription medications. As physicians and the FDA are both beneficiaries of the public trust, we must ensure that all of our actions and decisions place the public’s health first and foremost, above all other conflicting interests. Failure consistently to do so will erode the trust that our patients have in our medical recommendations. On behalf of my patients, and my profession, I urge you to make your decision grounded in science, the deliberative process of seeking the truth, not a process of compromises and appeasing the loudest voices in the debate.

Thank you.

Welcoming Open Arms?

The Conceal Carry movement has had significant success in the past two decades, and the Supreme Court has finally weighed in whether the 2nd amendment applies to individuals (it does).

Now we're apparently moving into the next phase of this movement: what's the fun of carrying a weapon if you have to conceal it?

This is an issue that I believe is best handled on the local level: the connotation of carrying a firearm in Kansas is far, far different than carrying a firearm in, say, Chicago. Let those decisions be made at a local level. To this point, we're also seeing a movement to invalidate local ordinances that allow specific places to ban guns (hospitals, businesses, etc) based on the desire of the owner. (It's fascinating to see how a group of people who feel their rights are being imposed upon are responding by ... imposing upon the rights of others.)

I have several concerns about unintended consequences of this movement. First of all, I actually won't be surprise to see research that shows crime (particularly armed robbery) declines in areas with conceal carry laws (though there isn't any solid data yet). While I don't believe that criminals are subject to rational behavior analysis (if they were, they wouldn't commit street crime to begin with), but there probably is some truth to the thought that if a criminal believed that there was a strong possibility that his intended victim was armed and would actually harm him in the encounter, the criminal mind might pursue crime in a less risky manner (such as property crime rather than armed robbery). (Note: doesn't open carry actually work against this? Conceal carry created "herd immunity" -- criminals don't know who out there is armed ... but open carry makes it obvious who to target and who to avoid.)

One of my biggest concerns about these laws is what I'll call the "Good Samaritan Friendly Fire" problem. Say an individual hears cries for help down a alley. He pulls out his weapon to investigate and intervene on the situation. Now, say a second person also hears the same cries for help, and at the same time sees the first individual carrying a weapon, heading down the alley. Police are trained to avoid shooting each other, and yet it still unfortunately happens. Citizens don't have that training, and are probably more prone to making that mistake.

But while that's a concern, it isn't a personal concern -- Good Samaritan Friendly Fire is a risk that a gun-toting citizen should understand that they are taking, but I'm not one. However, there is a way that every citizen could be put at risk by increasing the number of law-abiding people carrying guns. While many "rational" thieves will conclude that the benefits of robbery are outweighed by the risk that the target will be armed, some will come to the conclusion that the way to reduce that risk is to shoot first, and rob second. What would have been a simple hold-up carried out by the mere threat of a weapon will become an assault rather than taking the risk of being shot. That is one "rational" response to the incentives that are being created. And one that has a worse outcome for the victims.

The Supreme Court got it right.

So, it's been a bit of an eventful week in politics, and I wanted to weigh in on one of the more profound announcements that will potentially affect politics for years to come. I speak, of course, of the confirmation that Quinn Hunter's father is John Edwards.

Just kidding.... Well, actually Edwards *is* the father, but I'm joking that I would actually offer commentary about that National Enquirer scoop.

The big news today was the Supreme Court ruling on the Hillary Movie. Well, the ruling was about campaign finance laws, but it stemmed from the production and distribution of an anti-Hillary documentary.

I think the Supreme Court got it right.

I agree with the detractors who worry that this is furthering the "personification" of corporations, but I think it would eventually prove impossible to separate political speech by individuals and that of corporations. After all, a corporation could easily pay people to speak on its behalf. Okay, so we'd try to ban the exchange of money for speech (insane!), but that would only restrict unions and politcal action groups without barring political speech by the rich. Bill Gates doesn't have to solicit money from anyone to express his opinion widely, if he so chooses. I guess you could try to limit how rich people spend their money ... but that'd be a strikingly un-American way to promote an un-American idea of limiting speech.

It's a very slippery slope from blocking commercial speech to blocking the speech of individuals with a commercial interest in an election (like, say, tax-payers).

But this issue has more slippery slopes than Vail. As it was discussed in this case, what *is* the difference between releasing a movie before an election and releasing a book? Is it coherent to give written media broad protection, but not other forms of media? What are blogs, then? We often forget why broadcast media were once treated differently than other media: the radio frequency spectrum is "limited" and requires government regulation (in the form of protection of frequency ownership) to allow it to have value. (Without protection, we'd end up with cacophony where broadcasters would interfere with each other on every frequency, making all worthless in value.)

Perhaps what irks me most about the campaign finance issue is the fact that those that want to limit it seem to believe that people are unable to think, analyze and come to their own opinions. They are merely sheep that do what the talking box tells them to do. In the end, our democracy is founded on the decision that happens behind the voting booth curtain. No amount of money can "buy" an election with absolute certainty. Just ask Steve Forbes. (There is actually empiric evidence behind this.)

I agree that there is a worry that politicians would become (or appear) encumbered by donations by the wealthy, but that *can* be regulated. I'd like to repeat my simple campaign finance rules:

  1. Candidates for political office can accept donations only from individuals who can vote for them (registered voters in the appropriate precinct/county/state/nation).

  2. Candidates must disclose the source of all donations (above $20 or $50 or something trivial).

  3. Donations would include money and the cash-value of in-kind donations (like airtime, airplanes, etc).

There. That's all. The first rule would still restrict donations by corporations and unions (they aren't people, and so can't register to vote). Yes, monied interests could pay someone in a district to donate to a candidate, but that would have to be reported both by the candidate in the disclose. (And, curiously, to the IRS as income for that individual.)

The disclosure rule would let voters know who supports a candidate - which may not be a good thing. And the third rule exists to prevent candidates from coordinating with corporations/unions/etc. Corporations, unions, foreign governments, etc would all be allowed to buy ad time, publish books, film documentaries that push their political view -- they just couldn't coordinate with campaigns to do that.

So, rather than trying to divine if it is a corporation (not protected) or an individual (protected) speaking ... rather than trying to determine if the media is a protected form (books) or regulated (television) or something else (Internet) ... rather than flooding the courts each election with hair-splitting cases ... let's just open the flood gates.

And let the people sort out the truth, and render it behind the curtain in the voting booth.


Calling a Foul on My Own Team

As we speak, a few select members of the Democratic leadership are hammering out the final language for the health care reform. In very much the back-room dealing-making manner that they said they wouldn't resort to.

One of the signs of partisanship is the double-standard -- it's okay when my side does it, but not when the other side does. Sure, everyone attempts to explain away this by saying that this situation is different than that other situation, but just watch The Daily Show on any given night, and you'll see how flimsy those arguments are. But that doesn't stop them from being made. And if anyone does actually raise an issue with their own side's behavior, they risk being ostracized by the whole group, thereby punishing those who seek to consistently apply principles in a just way. (Aren't these the "factions" that George Washington warned us about?)

Well, that being said, I'm going to call a foul on my own team. While I (generally) agree with what we're going to get out of the health care reform, as we enter this final endgame, the methods are disappointing. Back in my LAD days, I used to show the entire "I'm Just A Bill" cartoon -- it's great entertainment, and surprisingly accurate for a 70's cartoon. But it does leave out one key step in the legislative process: the conference committee to reconcile differences between versions of legislation passed by each house. However, as we are currently learning, that conference committee isn't actually required -- using procedural steps and backroom agreements, they can get the same bill to each chamber without the official conference committee.

Why skip the conference? Well, from what I can gather, it's not because it could derail the process -- it's generally agreed that whatever came out of conference committee would get through Congress in one final vote. However, it would require several more of those hairsplittingly close procedural votes in the Senate, plus more time. So, in short, the Democrats are skipping the conference to save time, not to change the end result.

But the process matters. Or, it should matter. That's why we have laws, rules and regulations -- to establish the *way* we get things done. One of the significant strengths in our country is that while we may disagree with the content of a law proposed by the "other" side, we agree with the process for that proposal to become law (or die a quiet death in committee). It's that underpinning and consensus that lets us have debates and discussions. But it should be respected, because the desire to etch away at it for the need of political expediency is always present. And if your side contributes to that erosion, there's less there to hold the "opposition" back when it's their opportunity to make changes.

This does raise an interesting political and sociological discussion that I haven't entirely settled for myself: why are back-room discussions bad? In general, debates and decisions that are made by "representatives" should be public. Back in the day when only white men with land could vote, ballots were not secret because it was felt that since they were voting on behalf of their women and their property (both physical and human), that it was appropriate to know how they voted. As we wised up and figured out that both the woman, the landless, and the previous slaves might actually have an opinion of their own that was not represented by the pale penis people, the ballot became secret because it was now an act of self-interest to cast a ballot (what do I think is best for me and my country?).

Congressional votes are always public because this is a representative democracy -- we need to know how our representatives are voting to know if we want to keep them in office. But there is also a role for private discussions, particularly in the early stages of legislation as deals are made. Imagine how productive the process would be if everyone witnessed how their favorite project or ideal was offered up as a sacrificial bargain during negotiation? Those bargains not taken need not be know (but those that are made final should and must be publicly discussed and debated).

So, there is a role for private, backroom bargaining to hammer out the details. But the reality is that there will not be a full, public debate with back and forth negotiations and compromise in a public forum -- are we bypassing a necessary part of representative democracy? (For the most part, no -- the bill was debated in the open for weeks, but should there still be an opportunity for us to see who offered up what parts for compromise? That's the open question in my mind ...)

In terms of process, I see this as a foul on the Dems ... but not a reason for ejection from the game. There were many more flagrant fouls that were considered (using Reconciliation to pass the health care reform -- now that would have been a serious erosion of the process). But when the Dems are in the minority again (and it will happen, though probably not in 2010), they will have less trust established with their colleagues and less mutual respect for the agreed upon rules. When you are "the other side", it's best to be able to say, "Look, we followed the rules and the process to get our goals achieved ... you should too."


An awful smell coming from Washington

Liberal America has been overcome by nausea and malaise caused by an awful smell emanating from Washington, DC. I think it's the smell of sausage being made ...

Yes, the health care reform bill stinks. It smells to high heaven right now. It's just plain awful, and everyone near it is holding their nose and breathing through their mouths. Including the health care types, who don't even wince at the blast of a melanic stool or the stench of a gangrenous foot.

It's really bad, that thing they are cooking up in Washington. They've tossed out all of the fresh ingredients like the public option, and thrown in some seriously unhealthy stuff -- like an individual mandate to buy health insurance.

It reeks, indeed, but it's the only meal we're going to get served this year, or even this decade. And we're just going to have to swallow the swill that Joe Lieberman is dishing up if we want to have any hope of making a better health care system.

The Senate bill is undesirable for sure, but the status quo is worse. The status quo allows insurance companies to dump patients the moment they get sick. It allows insurance companies to stop paying out when patients cost them too much (and they get to define what "too much" is). And those are the people who can even get insurance -- those with pre-existing conditions are deemed Untouchables by the insurance industry.

Those are the options we face right now: reform that applies a few more patches around the edges and doesn't do much to fundamentally alter the system, or a status quo that lets 18,000 people die every year because they don't fit into the for-profit business model of insurance.

Pretty grim choices.

On one hand, we have the party that is a herd of cats. And on the other we have the Party of No! But remember, only one side is even offering a choice, even attempting to address the problems. To switch metaphors for a moment, at least the Dems are on their feet and stumbling around (occasionally even in the right direction). The GOP is plain passed out in the gutter. The GOP's hope for coming out ahead on this is that the Dems stumble into the path of an on-coming car. It's hard to describe either image as "leadership", but I'll side with the guy on his feet -- he at least has a chance of getting home.

As a physician, I know that it takes a long time and hard work for patients to take control of their illnesses and move to better health. And through every long change process, there are set backs and moments when it feels like things will never get better.
As doctors, we work with our patients through the hard times, and help them take the small steps that lead to health. We help them through the tough patches, but we don't abandon them when they have set-backs. We are partners with our patients through the whole process.

Our health care system has been seriously ill for a long time. It will take a long time to bring it back to health. We of all people should know that there isn't a magic pill that will cure all ills overnight. Our health care system has a chronic disease, that has to be overcome in small bits, day by day, through a life-long process. There is no magic solution to making our health care system better - only hard work and thoughtful effort.

Right now, we have a key moment to make critical decisions that will make the health care system better. Not every decision will be for the best, but we need to stick with our "patient" to help guide it through the long-term reform process: legislation, regulatory process, state-level responses, etc.
There have certainly been set-backs during this reform process, but we need to stay with the process and help guide the reforms, now and in the future. Our patient will not always make the best decisions - we need recognize that. And while we may not agree with those decisions, now is a critical time for us to be engaged and to continue providing our recommendations.

We need the Senate to pass something (anything!), so that we have a starting point for the debate in the conference committee. "Starting over now" will lead to a certain death - we'd be starting in a weaker place than where we were after Obama's election. This is our chance to any reform in this decade: insurance reforms, coverage expansion, malpractice models and payment reform ... all are necessary and better than than the status quo. We need to make this a victory, and use it as momentum for the next steps. Otherwise, we'll have more of the same: rapid cost increases, less insurance coverage, and more medical bankruptcies.

That smell from DC is foul, rank and nauseating. But it's better than the rotten, spoiled gruel we're eating right now.

Summary of HR 3962 for patients

[The below is a draft summary of the House legislation that I've created. Please feel free to add comments, clarifications, or additional questions]

What does this legislation do?
- It reforms the insurance industry to forbid basing premiums on pre-existing conditions or health status. Premiums may vary based on age, but only to a maximum 2:1 ratio between the highest and lowest premiums. Plans may no longer have lifetime or annual limits on spending, and out of pocket costs are capped. These rules apply to all plans, with time allowed for them to come into compliance. Currently existing plans will not need to meet these requirements.
- Creates a Health Insurance Exchange for individuals not covered by employers, Medicare or Medicaid. Businesses may also participate in the Exchange, starting with small firms in 2013. States may also create their own Exchanges. A Public Option will exist in the Exchange, funded entirely by its premiums (not through tax dollars).

Who is required to obtain health insurance?
- Individuals are required to have health insurance coverage. Failing to do so results in a fine equal to the lesser of 1) 2.5% of their adjusted gross income or 2) the average premium in the Exchange. Veterans and Native Americans are exempted.
- Employers must cover 72.5% of the cost of premiums for employees (65% for families), or pay into the Exchange to subsidize low-income individuals and families. Employers who do not provide qualified plans will pay 8% of payroll to subsidize employees seeking coverage in the Exchange.

How can I afford to purchase insurance through the Exchange?
- Affordability credits are provided to individuals and families with incomes less than 400% of the Federal Poverty Level ($88,200 for a family of 4 in 2009). Annual out of pocket costs for these individuals are also capped. Credits are not available to individuals who qualify for Medicare or Medicaid.
- Medicaid is expanded to 150% FPL ($33,075 for a family of 4).

Will I have to pay more in taxes?
- Taxpayers earning more than $1,000,000 (joint) or $500,000 (single) will pay 5.4% rate. There is also a 2.5% excise tax on medical devices. Contributions to health savings accounts are limited to $2,500. There are several other minor funding provisions.
- Employers must cover 72.5% of the cost of premiums for employees (65% for families), or pay into the Exchange to subsidize low-income individuals and families. Employers who do not provide qualified plans will pay 8% of payroll to subsidize employees seeking coverage in the Exchange.
- Small businesses (payroll less than $500,000) are exempt from 8% payroll contribution. Businesses with payrolls between $500,000 and $750,000 pay less than 8% on a graduated scale.

Will my Medicare coverage be affected?
- Medicare Part C (Medicare Advantage) plans will be required to limit cost-sharing (what you pay out of pocket for care) to be equal or less than traditional Medicare.

What about prescription drug coverage (Medicare Part D)?
- The Donut Hole in Medicare Part D is eliminated over several years.

Will a “death panel” pull the plug on Grandma?
- No.
- Qualified insurers are required to provide information about end-of-life planning to individuals. However, there is no obligation for a patient to establish advance directives or comfort care orders. The information cannot “promote suicide, assisted suicide, euthanasia, or mercy killing.”
- Comparative Effectiveness Research (CER) cannot be used to “mandate coverage, reimbursement, or other policies for any public or private payer.”

An ethical argument for the public option

As we enter the final stretch of the legislative process for health care reform, we are beginning to get an idea of what the final bill will look like based on the five existing bills: definitely regulation of the insurance industry (no more "pre-existing conditions"), most probably an individual mandate to obtain insurance (enforced by a fine or a tax), and maybe (?) a government-run public option to compete with the private insurers.

Is there any other place in our lives where the government mandates that we purchase a good which is only available from private vendors? Car insurance is similar, but there is no mandate to purchase car insurance unless you wish to be licensed to drive -- and many people are not licensed because they don't drive. Businesses often have requirements to carry certain kinds of insurance, but businesses aren't endowed with individual rights.

We do have laws in this country that compel mandatory attendance in school (with exceptions for home-schooling, etc). However in this case, the government also provides the means to meet that mandate: the public school system. (We are so lucky that Horace Mann lived in a different era ... in today's world, we'd have bitter partisan fights about creating a public school system and a "right" to a basic education, and we'd probably end up with a multitude of profit-seeking private schools who used their political influence to stop the creation of public schools.)

Is it ethical to institute a mandate for everyone, but not provide the means for filling that mandate? I'd argue no ... if we believe as a society that everyone should have health insurance (which is what the legislation does, via a democratic process), then it is also our obligation as a society to ensure that health insurance is obtainable. And the only way to *guarantee* the availability of insurance is to have a public-sponsored program.

Private companies are not permanent, nor are they necessarily stable. It's not a far stretch of the imagination to see a world where due to, say, a fiscal meltdown, all private health insurance companies suddenly go insolvent and are unable to offer new policies. Suddenly, we have a law that requires coverage, but the marketplace is unable to offer a product to satisfy that law. The failure is with the insurance companies mismanagement, but the penalty is enforced on the consumer. Through no choice of their own, Americans are penalized by the law.

I'd argue that it would be unethical to write a law that allows citizens to be put in such a bind. That's why I'd argue that a public-sponsored insurance option is a necessary part of any health care reform that also includes an individual mandate.

I realize that a focus on the individual mandate opens up libertarian arguments against it. However, I believe we have a right as a society to determine that some things are social goods, and that the state can use its power to tax and/or fine in order to enforce that social good. Again, education is similar. And so are the police and fire departments -- people are required to pay taxes (under penalty of imprisonment) to support those endeavors because there is a public good generated by having those services available to everyone. And it is much more efficient to have everyone paying into the system to support those departments than to have, say, a "fee for service" police department. ("Welcome to Cops 4 Less: Filing a robbery claim will cost $500, charging someone with assault will cost $350 and don't even ask about investigating white-collar crime -- that'll cost you an arm and a leg.")

Finally, turning to the perpetual argument against the public option: it'll drive private companies out of business. First, I doubt it -- private firms will find markets where they can deliver value to customers (perceived or real), and people will pay for that additional service above what the public option offers (see: MediGap policies). Secondly, even if it did, that would be only because the public option was more efficient than private firms (they couldn't offer additional value, so they went out of business), so we'd be doing that same task of providing insurance to the population at a lower overall cost to society. What isn't to like about being more efficient in 16% of our economy? Oh, that's right, there's less room for profit-seeking enterprises to capture profit without providing additional value.

Which brings me to my concluding point: health insurance reform with an individual mandate but without a public option is nothing more than the "Health Insurer Bail-Out Act of 2009" -- we'd be giving tax dollars straight to the private firms, who have a market guaranteed by law. Shouldn't we demand that they at least compete for our tax dollars?


Conservatives and Lies

The heat of August has settled in, and the Congress has fled the swamp of Washington, DC. After the townhall forums this month, I suppose a few wished they had never left.

We knew the debate would get ugly and heated, but what I think has truly caught me off guard is the degree at which the discussion is occurring about topics completely disconnected from reality. There are no "death panels" in the legislation (or even effectiveness review boards, which could become "death panels"). There is no plan to socialize the health care system (let's recall the definition of socialize: place it under government control, like GM or banks that are taken over by the FDIC). The public health insurance option, which isn't even expected to be in the Senate Finance legislation, wouldn't have the support of the government and would have to function like a private insurer in the private market (minus the profit-seeking). And even that is about to be abandoned. (Apparently, winning an election and a majority of Congress, while running on the domestic issue of health care reform, isn't enough of a mandate to actually pass the ideas that were talked about during the campaign.)

I understand the political process, and how winning in the public relations battle can be more important than the actual legislation (Harper's has an article about how the PR battle has replaced the actual wording of the Durban Accords on race in many minds). But our public servants (elected officials like Senators, former Alaska governors, etc) are not correcting out and out lies being circulated about the legislation by the conservative commentariat. That is highly disappointing, and I'm having a hard time coming up with similar examples of liberal politicians promoting demonstrably false statements for political gain. Liberals lie about sex scandals, but so do conservatives.

I would actually expect liberals to have multiple "truths" -- they are the ones of "relative truth" after all, where no culture, society or group has a monopoly on the Truth. But I am disappointed in the conservatives: they are the ones of "absolute truth" -- and what is written in legislative language is pretty much absolute, provable and undeniable. Where are their principles? (You know, those things you stand by even when it isn't immediately to your own self interest to do so?)

Despite my personal political leanings, I tend to respect conservatives for the role they play in ensuring that liberals don't go off the deep end with their "brilliant" ideas. You know, a sounding board, a cooling chamber, a parental voice of reason when the kids want to have candy for dinner. I think this was expressed well by a founding father of the modern conservative movement, William F. Buckley, when he founded the National Review: "It stands athwart history, yelling Stop, at a time when no one is inclined to do so, or to have much patience with those who so urge it." (Full disclosure: I have subscribed to NR for a dozen years - I'm often amazed that it hasn't undergone spontaneous combustion when it has been placed in my mailbox next to Harpers, Atlantic Month, New Republic, the Nation, etc.) Buckley made the Republican party respectable by ousting the influence of the John Birch Society and bringing it back to reality.

But recently, there was an insight into the Buckley family that I did not expect at all. Christopher Buckley, William's son, recently wrote about his life in the Buckley household. Now, it stands to reason that he did not have a wonderful childhood (he did, after all, endorse Barack Obama for President), but his description of his mother stunned me:

"Over the years, I heard Mum utter whoppers that would make Pinocchio look button-nosed .... I remember the time I first caught Mum in some preposterous untruth, as she called it... I looked at Mum and realized — twang! — that she was telling an untruth. A big untruth. And I remember thinking in that instant how thrilling and grown-up it must be to say something so completely untrue — as opposed to the little amateur fibs I was already practiced at, horrid little apprentice sinner that I was, like the ones about how you’d already said your prayers or washed under the fingernails. Yes, I was impressed. This was my introduction to a lifetime of mendacity. I, too, must learn to say these gorgeous untruths. When Mum was in full prevarication, Pup would assume an expression somewhere between a Jack Benny stare and the stoic grimace of a 13th-century saint being burned at the stake. He knew very well that King George VI and Queen Elizabeth did not routinely decamp at Shannon. The funny thing was that he rarely challenged her when she was in the midst of one of her glorious confections. For that matter, no one did. They wouldn’t have dared. Mum had a regal way about her that did not brook contradiction.

So, the founder of modern conservativism, who launched a magazine - and a movement - to stop history from running over the facts, lived with a serial speaker of "untruths" and had given up trying to stop it.

I think I'm beginning to understand conservatives, after all...

But why does it work for conservatives to completely make things up? On one hand, we go back to the fact that their opponents are the believers in multiple truths: there is always some piece of truth in a statement, right? Even if that "truth" is only the fact that the person saying it thinks what they are saying is true, despite all evidence to the contrary. It is important to acknowledge that truth, or else we might hurt someone's feelings and self-esteem.

Secondly, we are witnessing the failings of the profession that sees itself as the seekers of truth in our lives: journalists. As a commentator in the Washington Post wrote today:

Conservatives have become adept at playing the media for suckers, getting inside the heads of editors and reporters, haunting them with the thought that maybe they are out-of-touch cosmopolitans and that their duty as tribunes of the people's voices means they should treat Obama's creation of "death panels" as just another justiciable political claim. ...It used to be different. You never heard the late Walter Cronkite taking time on the evening news to "debunk" claims that a proposed mental health clinic in Alaska is actually a dumping ground for right-wing critics of the president's program, or giving the people who made those claims time to explain themselves on the air. The media didn't adjudicate the ever-present underbrush of American paranoia as a set of "conservative claims" to weigh, horse-race-style, against liberal claims. Back then, a more confident media unequivocally labeled the civic outrage represented by such discourse as "extremist" -- out of bounds.

(Side note: that mental health clinic in Alaska was one of the things that WFB brought up as an issue with the Birch Society ... see, conservatives used to actually care about the truth.)

One of the reasons I pay such close attention to the travails of the profession of journalism is that they are another profession that have their role in society undermined when profits are the sole pursuit (in their case, via the pursuit of sensational stories to drive up viewers rather than a discussion of facts and issues of the day). Actually, the very definition of a "profession" implies that as a class, the group provides a service to society that cannot be fully marketized; same goes for lawyers, clergy, police, etc. Democracy needs a profession to seek the truth of what is happening to real people, not to spout talking points generated by those who are currently in power. You know, the whole "Power to the powerless and afflict the comfortable."

I am worried that journalism as a profession will not survive our adoration of "the marketplace". And I'm worried that my profession will be next.


Reviewing the House Bill

I skimmed through a 41-page summary (PDF) of the House version of the Affordable Health Choices Act (PDF, 1018 pages) looking for the sections most relevant to physicians. There are lots of details that will be of interest to physicians in various areas of medicine, but I tried to capture the key portions.

Below is that provider-specific summary of that summary. I've tried to ensure accuracy, but if there's something that isn't right, please let me know. I encourage you to read the original sources if you have any questions about the details.

The House Tri-Committee bill expands health insurance coverage primarily through two mechanisms: the creation of a Health Exchange and expansion of Medicaid.

Plans that are sold through the Exchange will be required to meet minimum standards, and can offer more benefits to obtain one of several higher benefit levels. An advisory committee chaired by the Surgeon General would be responsible for making recommendations to HHS about the coverage required to meet the various levels of plans in the Exchange.

Companies will still be able to offer packages outside of the Exchange that do not meet the Exchange standards (but would have to meet the appropriate state regulations, as is currently the law).

The Exchange will have a step-wise availability to the population. It will initially be open to those currently in the individual market, as well as employees of firms with less than 10 employees. In subsequent years, the Exchange will become available to more employees at larger firms until everyone has the option in year 5. Medicaid-eligible families would be enrolled only in Medicaid rather than the Exchange for the first five years, then would be able to enroll through the Exchange. There will be credits available to families up to 400% Federal Poverty Level for plans purchased through the Exchange. These credits will not be available to families currently offered insurance through an employer unless that plan costs more than 10% of their income.

The Public Health Insurance Option would start in 2013, to be available through the Exchange. It would be under the same regulations as the private insurance. Premiums will be geographically-adjusted and must cover the cost of the program (ie, no tax dollar support). Payment rates for the first three years (2013-15) will be based on Medicare rates plus 5%. After three years, the HHS can change the rates as necessary to ensure access, affordability and efficient delivery of care. The payment system can further be changed to develop new ways to reimburse for care to enhance health outcomes, reduce health disparities, manage chronic illnesses and encourage care-integration.

The Public Health Insurance Option can negotiate for drug prices. The Medicare Part D Donut is phased out by 2023. Part D beneficiaries can change plans mid-year if a formulary change adversely affects them.

Providers currently participating in Medicare would be automatically enrolled in the Public Health Insurance Option unless they opt out. “Balance billing” would be limited. The Sustainable Growth Rate is repealed. Medicare will increase payment for primary care services and psychiatry. Primary care reimbursement will be allowed to increase at a faster rate than other providers. It also provides incentives to physicians practicing in areas that provide cost-efficient care (lowest quintile of per-capita costs nationally).

Payment to hospitals will be linked to re-admission rates for three conditions (to be named later) starting in 2011. Integrates post-acute care providers into the payment system in the following years.

Medicare will have an alternative payment system through Accountable Care Organizations, which are physician grouped around a common delivery system (hospital or integrated practice). Spending will be benchmarked; quality care delivered at reduced costs will be rewarded.

Demonstration projects for language services, which will be studied by IOM.

Eliminates cost-sharing for preventive services in Medicare and Medicaid. Requires smoking cessation to be covered as prevention by State Medicaid programs.

Cost effectiveness research center in AHRQ to be guided by public/private stakeholder commission. The commission cannot mandate coverage for public or private plans (advisory role only).

Physician Payment Sunshine Provisions requires disclosure of any payment from a device or pharmaceutical company to a provider of value above $5.