Health Beat

Is Your Yearly Physical a Waste of Time?

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Could the Media Derail Health Care Reform?

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The Dangers of Do-It-Yourself DNA Testing

This article originally appeared on Health Beat.

Recently, Time magazine listed the retail DNA test as its best invention of 2008 (thanks to Kevin M.D. for the tip). The best?  Maybe one of the most worrisome.

Time specifically highlights the do-it-yourself DNA testing kit from 23andMe, a California-based corporation named after the 23 pairs of chromosomes in each human cell.  The company sells $399 DNA kits that consist of a test tube in which you spit and send to the company's lab. There, over the next 4-6 weeks, researchers extract DNA from your saliva and map your genome, putting the results online. You can access the results through the web and navigate a guide to your genes that estimates "[genetic] predisposition for more than 90 traits and conditions ranging from baldness to blindness." 

Admittedly, this sounds pretty cool. As Time gushes, "in the past, only élite researchers had access to their genetic fingerprints, but now personal genotyping is available to anyone who orders the service online..." But look closer at the commoditization of DNA testing and the novelty wears off pretty quickly.

By pinpointing specific genes associated with certain diseases, a 23andMe gene read-out can inform a user of his or her susceptibility to those conditions. It turns out this is a lot less useful than it might seem. For example, Time reports that one test showed that the husband of 23andMe's founder has a rare mutation that gives him an estimated 20 percent to 80 percent chance of getting Parkinson's disease. The couple's child, due later this year, has a 50 percent chance of inheriting this mutation, and thus his dad's risk of Parkinson's.

At this point, the parents-to-be have to worry that their kid will have a mutation associated with an incurable disease. If he has it, they also have to fret that he has anywhere from a one in five to a four in five chance of actually contracting the disease. Really, how helpful are these numbers? That's a big range of probabilities. I wager it doesn't feel terribly good to be tracking the genetic lottery of your son's health, disease by disease.  In fact, I imagine that it's downright harrowing.

Dr. Alan Guttmacher, acting director of the National Human Genome Research Institute of the National Institutes of Health, agrees. In September, he told the New York Times that "[DNA testing] can be neat and fun, but it can also have deep psychological implications" because it can profoundly influence the way we view ourselves, our loved ones, and our relationship to the world. As Guttmacher told Time, "a little knowledge is a dangerous thing."

Here Guttmacher isn't just talking about the strange helplessness of knowing the ever-so-approximate probability of your child getting sick. He's also speaking to the fact that DNA tests themselves only provide a little knowledge -- just one small piece of the complex puzzle that is our health. Unfortunately, DNA tests often promise much more than this. One company, Navigenics, is actually dedicated to reading your DNA and diagnosing you with a set of medical risk factors that you then discuss with an appointed "genetic counselor." The idea is that genetic tests reveal some sort of fundamental physiological truth; a complete and comprehensive assessment of our health.

It's true that some conditions, like cystic fibrosis and Huntington's disease, have been scientifically proven to be associated with particular genetic mutations. But many other conditions have not been shown to have a genetic origin -- particularly when that gene is detected without an intimate understanding of environmental factors surrounding a patient, as it is the case when researchers on the other side of the country analyze your spit. 

In light of this fact, the Genetics and Public Policy Center, a project of Johns Hopkins University and Pew Charitable Trust, warns that many consumers "might have difficulty distinguishing between tests widely used and accepted by medical professionals...and those whose validity is unproven in the scientific literature." Customers will see their genetic print-out, with risk assessments for particular illnesses tagged on each gene. But they won't have a sense of how the DNA testing company calculated that number -- i.e. how much it reflects established medical research or a best guess from a company trying to convince you of its product's predictive possibilities.

Unfortunately, the latter seems to be more plausible. In 2006, the Government Accountability Office (GAO) purchased 14 DNA tests from four different websites and sent in samples. The office found that "the results from all the tests GAO purchased mislead consumers by making predictions that are medically unproven and so ambiguous that they do not provide meaningful information to consumers."

From GAO's saliva samples, the companies sent back risk predictions for conditions like diabetes and osteoporosis with little qualification, even though "scientists have very limited understanding about the functional significance of any particular gene, how it interacts with other genes, and the role of environmental factors in causing disease." In other words, the tests were spitting out numbers and warnings even though the genetic causality of these conditions "cannot be medically proven."

Further, many other results were all but "meaningless. For example, [the companies reported that] many people 'may' be 'at increased risk' for developing heart disease." But this is true for pretty much everyone, "so such an ambiguous statement could relate to any human that submitted DNA." The laughable superficiality of the companies' test results carried over into lifestyle information that GAO provided: when the office told a company that the patient from whom the sample derived smoked, the DNA company recommended that they stop smoking. When the patient reported that he had quit, the company "gave recommendations to continue to avoid smoking." Gee, thanks -- is that really worth $400?

Ultimately, in the words of Dr. Muin Khoury, director of the National Office of Public Health Genomics at the Centers for Disease Control and Prevention, "the uncertainty [of medicine] is too great," to view DNA testing as a sort of medical crystal ball. Even within the context of our genes, the possibilities are endless. To its credit, Time points out that "many diseases stem from several different genes and are triggered by environmental factors. Since less than a tenth of our 20,000 genes have been correlated with any condition, it's impossible to nail down exactly what component is genetic."

In fact, even when doctors do know that there's a genetic component to a given condition, they're not always sure which genes to look at. For example, in 2006 the Boston Globe noted that "there are hundreds of mutations in two well-known breast cancer genes, BRCA1 and BRCA2, for which reliable commercial tests exist. A woman could be told that she didn't have the common mutations but might still be at high risk from less common mutations or a different gene altogether..." Translation: even though we know there's a genetic component to breast cancer, it's very difficult to pinpoint which gene is the problem -- particularly if the only way of communicating with a patient about the issue is watered-down risk probability.

Meanwhile, the vagueness of DNA test results works in the favor of testing companies. If they keep things simple and superficial, they can make cross-promotion easier. In the GAO study, for example, the DNA test results were synched with expanded product offers such as dietary supplements, which had only a tangential relationship to the patients' test results.

This sort of aggressive marketing is direct-to-consumer medicine at its most profitable. Companies often want to convince patients that they have a certain condition and then sell them on the cure. In prescription drugs, this "disease mongering" has usually been about listing symptoms to get people scared. But DNA testing kicks things to another level: convince people that they are actually hard-wired to contract a particular disease, and your cure becomes that much harder to resist.

It's no wonder that experts at Johns Hopkins are worried that "advertisements may...underemphasize the uncertainty of genetic testing results, or exaggerate the risk and severity of a condition for which testing is available, thus increasing consumer anxiety and promoting unnecessary testing." Given what we've seen in direct-to-consumer medicine up until now, this is a very reasonable fear.

Another plausible concern is that DNA tests, in their superficiality and over-simplification of medicine, will be routinely misinterpreted by patients. Time cites the case of Nate Guy, a 19-year-old in Warrenton, Va., who "was relieved that though his uncle had died of prostate cancer, his own risk for the disease was about average," according to his 23andMe test. This sounds uplifting until you realize that, by the age of 70, the vast majority of men have prostate cancer. Almost all of them will die with prostate cancer, not from it. (Something else will kill them before this very common, but usually slow-growing, cancer catches up with them.)  An "average risk" of prostate cancer means you'll probably get prostate cancer and live with it for years, just as do nearly all older men.

Presumably, Guy doesn't know this. One gets the sense that he thought his uncle died of prostate cancer because he died with prostate cancer, and that this fact meant that his uncle had been uniquely susceptible to the disease. Now Nate finds out he has an average level of vulnerability and thinks that he won't get prostate cancer. Statistically speaking, none of this is probably true -- but this is the sort of reasoning that happens when patients are confronted with misleading, sparse data about their health, devoid of a broader medical context.

One can imagine that, had Nate been disheartened with the results of his test, he would have similarly embraced the definitiveness of the results and undergone unnecessary prostate screenings throughout his life -- screenings which have never been shown to actually improve survival rates. Either way, Nate's taking the wrong message from his genome. Indeed, the likelihood that the patient will go for more screenings -- just to be safe -- combined with the fact that people are paying $400 a pop for a test which vaguely suggests whether they may or may not contract a disease makes DNA tasting a profoundly cost-ineffective health care option.

Genomics is a field that's new and exciting; scientists will and should pursue it. But it's probably not something you should try at home. From what we've seen so far, do-it-yourself DNA testing risks exacerbating many of our most pressing health care problems: the deceitfulness of for-profit medicine, the dangers of direct-to-consumer health care, the glut of wasteful, potentially harmful, screenings, and the general misconception that -- if our gizmos are fancy enough -- we can all live forever.

How John McCain Would Dismantle Medicare

This article originally appeared on Health Beat.

No doubt you've seen the ads. Barack Obama claims that John McCain plans to hollow out Medicare, arguably the most popular social program in America.

McCain says that just isn't so.

The controversy began early this month when the Wall Street Journal reported that McCain plans major reductions in Medicare and Medicaid spending totaling $1.3 trillion over the text ten years. This will help pay for his health care plan. Douglas Holtz-Eakin, McCain's senior policy adviser, told the Journal that "the savings would come from eliminating Medicare fraud and by reforming payment policies to lower the overall cost of care." 

Without question, there is money to be saved if Washington cracks down on Medicare and Medicaid fraud. But before reaping any savings, the government first would have to spend money to ferret out the fraudulent claims. And no one believes that Washington could recover anything close to $1.3 trillion. Meanwhile, "reforming payment policies" seems to suggest that McCain plans to pay doctors and hospitals less, at a time when many Medicare patients are having a hard time finding a primary care physicians -- precisely because Medicare's fees are already so low. This could reduce access to care.

Barack Obama quickly went on the attack with ads warning that McCain would take "Eight hundred and eighty-two billion from Medicare alone...requiring cuts in benefits, eligibility, or both."

McCain's camp fired back, arguing that McCain had no intention of slashing benefits. The "savings"  would come from eliminating fraud, accelerating the computerization of health records, speeding the use of generic drugs, eliminating government subsidies for private Medicare Advantage plans, and  requiring high-income beneficiaries to pay more for pharmaceuticals,.

Let's look at this list, item by item. While electronic medical records could reduce waste in the long run, experience has shown that it takes at least ten years for healthcare IT to begin to pay off. In the meantime, where would the Senator find the money to install the technology and train doctors and hospital staff to use it? Electronic medical records would be a fine investment: but this is not a way that Medicare can save billions over the next decade. Speeding the use of generics should reap some savings -- though if you buy generics, you have probably noticed that prices are spiraling.  As for eliminating the bonus that Medicare now lavishes on private insurers that offer Medicare Advantage, that would trim spending by $16 billion. But that's still far from the $1.3 trillion that McCain aims to save.

Finally, what about the last item: "requiring high-income beneficiaries to pay more for pharmaceuticals"?  Let me suggest that this gets to the heart of the matter. For the goal here is not so much to raise revenues for Medicare as to shrink the size of the program. 

When it comes to McCain's plans for Medicare, the Wall Street Journal story is only the tip of the iceberg. If you want to understand McCain's intentions toward Medicare you need to realize that his objections to the program are firmly grounded in a conservative ideology that can be traced back to Ronald Reagan. From a conservative point of view, the problem with Medicare is that it covers everyone.

This explains why both President George Bush and Senator McCain have supported "means-testing" benefits, charging some seniors more than others. It also sheds light on why Sarah Palin quoted Ronald Reagan in her closing statement during the vice-presidential debate earlier this month.

McCain's Advisers Send a Signal

Begin with Palin. During the October 5 debate (the day before the Wall Street Journal story about McCain's new plan to fund his healthcare plan appeared), Sarah Palin turned to Reagan, as she reminded her audience that if we want to protect our liberties, we must be vigilant: "It was Ronald Reagan who said that freedom is always just one generation away from extinction. We don't pass it to our children in the bloodstream; we have to fight for it and protect it, and then hand it to them so that they shall do the same, or we're going to find ourselves spending our sunset years telling our children and our children's children about a time in America, back in the day, when men and women were free."

Some observers took this moment as an example of Palin's naiveté. Apparently she didn't know that these famous lines came from a speech that Ronald Reagan had recorded for the American Medical Association (AMA) in 1961, railing against the evils of that dark plot to undermine our liberties...Medicare.

Palin probably didn't know the source of the quotation. But the McCain advisers who prepped her for the debate most certainly did. Those lines are treasured by Reagan's many admirers.  By quoting that particular speech, the McCain camp was signaling how it views Medicare -- the day before the Wall Street Journal would announce that McCain planned to radically cut Medicare's funding. To understand the message, it's worth going back to 1961.

Reagan Leads a Secret Operation Aimed at Housewives

At the time, the Democrats were proposing, the "King-Anderson" bill, a proposal, backed by President John F. Kennedy, that would create a program much like modern Medicare, covering all Americans over 65. The AMA vigorously opposed the legislation. The physicians' guild saw Medicare as one step forward on the slippery slope toward "universal coverage," which the AMA called "socialized medicine."

Enter the Woman's [sic] Auxiliary of the AMA an organization composed primarily of the wives of member physicians. In an essay titled "Operation CoffeeCup: Ronald Reagan's Effort to Prevent the Enactment of Medicare," Larry DeWitt, a public historian for the Social Security Administration, describes how the Woman's Auxiliary was asked to launch a special high-priority initiative under the title of WHAM, Women Help American Medicine in 1961.

"The avowed aim of WHAM was bluntly stated," DeWitt reports: "This campaign is aimed at the defeat of the King-Anderson bill of the 87 th Congress, a bill which would provide a system of socialized medicine for our senior citizens and seriously curtail the quality of medical care in the United States." (Thanks to The New Republic's Jonathan Chait and Dr. SteveB on Daily Kos for calling attention to DeWitt's excellent essay.)

"The AMA's campaign against the King-Anderson version of Medicare was a complex, extensive, and well-financed lobbying tour-de-force," DeWitt continues. "Many aspects of the WHAM campaign were very public and visible. The AMA placed advertisements in major newspapers and funded radio and television spots, all deploying the usual red-brush of 'socialism,' and even the specter of jack-booted federal bureaucrats violating 'the privacy of the examination room.'"

But DeWitt reveals, "there was also a more stealthy component to the campaign," one that depended for its success on its sponsorship and origins being hidden from the members of Congress who would be lobbied under its aegis. This was Operation CofffeeCup," and Ronald Reagan was its star.

Operation CoffeeCup arranged a series of coffee-klatches hosted by the members of the Woman's Auxiliary. "The Auxiliary members were instructed to downplay the purpose of the get-to-gathers," DeWitt explains, "depicting them as sort of spontaneous neighborhood events: "Drop a note -- just say 'Come for coffee at 10 a.m. on Wednesday. I want to play the Ronald Reagan record for you.'"

In 1961, Reagan's film career had faded and he was contemplating a move into politics.  With that in mind, in agreed to become the AMA's spokesperson, recording a 19-minute LP vinyl entitled "Ronald Reagan Speaks Out Against Socialized Medicine." (You can hear Reagan's silky voice on YouTube.)

Reagan's impassioned address was followed by an 8-minute speech by an unnamed announcer. Reagan's work on behalf of the AMA was, listeners were assured, unpaid (although there was no mention of the fact that Reagan's father-in-law was a top official of the AMA) and was motivated only by his own strong political convictions on the issue.

Meanwhile, "the attendees at these coffees were trained and encouraged in writing apparently spontaneous letters to members of Congress expressing their strong opposition to the pending King-Anderson bill. It was essential, the attendees were instructed, that their letters appear to be the uncoordinated, spontaneous, expressions of a rising tide of public sentiment."

Ronaldreagan Reagan's speech was "a determined and in-depth attack on the principles of Medicare (and Social Security)," DeWitt points out, "going well beyond opposition to King-Anderson or any other particular piece of legislation."

In the recording, Reagan described "the idea that all people of Social Security age should be brought under a program of compulsory health insurance" as an "imminent threat." He emphasized the breadth of the plan, explaining that it would cover, "not only our senior citizens" but "those who are disabled" (just as Medicare does today.)

Reagan urged his listeners to write to their Congressmen telling them that "We do not want socialized medicine...[we] demand the continuation of our traditional free enterprise system.

"Call your friends, and tell them to write . . . If you don't," Reagan warned, "this program I promise you, will pass just as surely as the sun will come up tomorrow. And behind it will come other federal programs that will invade every area of freedom as we have known it in this country, until, one day... we will awake to find that we have socialism. And if you don't do this, and if I don't do it, one of these days, you and I are going to spend our sunset years telling our children and our children's children, what it once was like in America when men were free.

Despite efforts to keep Operation CoffeeCup under the radar, Reagan's role in the AMA campaign was revealed, in a scoop by Drew Pearson in his Washington Merry-Go-Round column, "Star vs. JFK" :
Pearson wrote: "Ronald Reagan of Hollywood has pitted his mellifluous voice against President Kennedy in the battle for medical aid for the elderly. As a result it looks as if the old folks will lose out. He has caused such a deluge of mail to swamp Congress that Congressmen want to postpone action on the medical bill until 1962. What they don't know, of course, is that Ron Reagan is behind the mail; also that the American Medical Association is paying for it.

"Reagan is the handsome TV star for General Electric...Just how this background qualifies him as an expert on medical care for the elderly remains a mystery."

Nevertheless, Reagan and the AMA carried the day. Medicare legislation would not pass until 1965, after JFK had been assassinated. 

DeWitt stresses that Reagan objected to Medicare because it was universal. As an alternative, both Reagan and the AMA preferred the Kerr-Mills bill, which offered an early version of Medicaid, paying medical bills for those on welfare, or those who could qualify as indigent. "By restricting federal programs to the 'truly needy' these programs could be kept small," DeWitt explains, "involving few if any middle-class or upper-class Americans. . .."

Medicare, by contrast, was a program that included all seniors as well as the disabled. Based on a collective vision of society, it was a program that might create social solidarity -- as indeed it would. And conservatives knew that there was a danger that when younger Americans saw how well Medicare worked, they might say "we want that too." Some might begin talking about "Medicare for All."

So Reagan argued against universality: "Now what reason could the other people [i.e. the Democrats] have for backing a bill which says we insist on compulsory health insurance for senior citizens on a basis of age alone regardless of whether they are worth millions of dollars, whether they have an income. . . whether they have savings?" he asked. "I think we could be excused for believing that . . . this was simply an excuse to bring about what they wanted all the time: socialized medicine."

When Medicare legislation finally passed in 1965, some in Congress continued to argue that more affluent Americans should not be eligible. But the program's supporters rejected that idea. They did not want Medicare to become "a poor program for the poor." They realized that what makes Medicare special -- and so popular -- is the fact that it treats all Americans over 65 equally.

McCain Echoes Reagan's Position

Conservatives do not understand this. Or perhaps they do.  In 2003, as part of a veiled attempt to privatize Medicare, the Bush administration opened the door to mean-testing, hiking premiums on Part B of the program for Americans with incomes  over $80,000 -- $160,000 for couples).

Seniors already had seen serious hikes in Part B premiums. "Between 2000 and 2007, all Medicare beneficiaries faced average annual increases in Part B premiums of nearly 11 percent," the Medicare Payment Advisory Commission (MedPac) pointed out in its March 2008 report. "Over the same period, Social Security benefits, grew by just 3 percent a year.

The new increase for wealthier seniors was slipped into the Medicare Modernization Act of 2003, the reports: "a Republican dominated committee quietly added a provision to  the Act, which was not included in the versions passed by the House or Senate, that would add a surcharge to the Part B Medicare premium for more affluent seniors. The 13 percent surcharge will begin in 2007 and be phased in over three years. According to the Congressional Budget Office, the means test will affect about 1.2 million beneficiaries in 2007 and 2.8 million by 2013. Medicare has made no public mention of this change, not even in the July fact sheet on Part B costs, which estimated the Part B premium for 2007 would be less than $100 per month."

Today, the surcharge has kicked in, driving a wedge into the Medicare program. For the first time since Medicare's creation 43 years ago, seniors are no longer paying the same amount for the same services. By January 2009, higher-income beneficiaries will be paying 1.4 to 3.2 times the standard Part B premium, depending on their incomes.  The standard premium for individuals earning less than $85,000 will be $96.40.  By contrast, more affluent seniors will pay premiums that range from $134.90 to $308.30.

And now John McCain has proposed more means-testing, arguing that Medicare beneficiaries with incomes over $82,000 should also pay more for Medicare  Part D, the prescription drug benefit. Echoing Reagan's objection to covering the wealthy under Medicare, McCain has called the drug benefit a "new and costly entitlement" that included many people "who could buy insurance on their own without government help -- people like Warren Buffet and Bill Gates. By making them pay more for their medicines than some worker who spent his career in the coal mines, the country could save billions of dollars that could be returned to taxpayers or put to better use."  According to McCain adviser Douglas Holtz-Eakin,  the  proposal would affect the richest 5 percent of Medicare beneficiaries and save the system about $2 billion a year.

On the face of it, this sounds fair. Bill Gates doesn't need my Medicare dollars. But McCain isn't talking about only excluding billionaires. He proposes making Medicare less attractive to a large swathe of the upper-class and upper-middle-class -- everyone earning over $82,000 ($164,000 for couples).

And why stop there? As Trudy Lieberman pointed out in the Columbia Journalism Review, in April, McCain adviser Douglas Holtz-Eakin tipped his hand when he told the Washington Post:  "You could make this as aggressive as you want to get more savings."  In other words, Lieberman added, "if the government saves $2 billion by making couples with incomes greater than $164,000 pay higher premiums, it could save $6 billion by moving down the income ladder to, say, $100,000 or even less."

"Many health care advocates see McCain's proposal as just another opening to privatize and destroy Medicare as a social insurance program, under which everyone who has paid into the system is entitled to equal benefits as a matter of right," Lieberman observed. "If drug benefits, [like part B premiums] are based on income, critics fear that support for the program will eventually erode as those with more choices and more money will opt out of the program and buy coverage from private insurers."

After all, at a certain point some upper-middle class and many upper-class seniors may well decide that they could get better care at a lower cost if they dropped out of Medicare Part B (which, like Part D, is voluntary) and used the $308 monthly premiums to purchase a plan from a private insurers. One can easily imagine insurers offering seniors relatively low-cost high-deductible plans that cover what Part B and D cover -- -physicians' visits, out-patient care and prescription drugs.  (Meanwhile, Medicare Part A would continue to shield seniors from the charges that even the wealthy fear: hospital bills.)

Switching to private insurance to cover doctors' bills would offer well-heeled beneficiaries some advantages.  Today, many doctors are refusing to take Medicare patients because the fees Medicare pays many physicians are low.

Wealthier seniors might prefer a private plan that lets them choose from a wider range of physicians. If they switched to private insurance, they could pay down their deductible while giving their doctors say, 15 to 20 percent more than Medicare would allow.

Of course, this would mean that even more doctors would refuse Medicare, leaving middle-class and upper-middle class seniors who earn less than $82,000 (and pay only $96 for Part B) with many fewer physicians to choose from. In this way, Medicare would become a two-tier program.

"Those left in Medicare will likely be the poorest and the sickest with few options," Lieberman points. Experience tells us that private insurers will shun sicker seniors, leaving them on Medicare, where they would push the program's premiums ever higher.  Meanwhile, healthier, wealthier seniors who opt out of Part B and Part D will be opting out of what Lieberman rightly describes as "a compact among generations and made it possible for people to have health care when they are old and need it."

Under this scenario, that compact would be threatened. After all, if some seniors begin opting out of Part B, younger, affluent Americans might well ask, "Why should I continue to pay the full payroll tax for Medicare? I only plan to use Part A. I'll let the government know I'm not interested in Part B and they can cut my contribution accordingly." This leaves just one question: how would Medicare stay afloat if only lower-income employees are shelling out the full tax?

Finally, how confident do you feel that private insurers would reimburse for all of the benefits that Medicare now covers? What would happen to upper-middle class seniors who purchased a high deductible plan if their retirement savings suddenly swooned? Would they find themselves putting off needed care because they couldn't afford the deductible? Would Medicare still be there if they decided to switch back? For decades, Medicare has served as a safety net that all Americans could count on -- rich or poor, sick or well.  This is why we call it a "social safety net."

The Conservative Agenda

Keep in mind that when conservatives talk about means-testing, their goal is not to put Medicare on a firmer financial footing by raising co-pays for wealthier beneficiaries. Their aim is simply to drive more affluent seniors out of Medicare and into the arms of private insurers. At that point, health care advocates warn, Medicare would become welfare for low-income seniors and middle-class seniors. And just have much political support would it have then?

Finally: even if McCain is not elected, keep an eye on Congress. There are more than a few legislators who would like to gradually shrink Medicare, killing the program by inches.

One cannot help but remember what House  Speaker  Newt Gingrich said in 1995, when calling for Medicare cuts: "We don't want to get rid of [Medicare] in round one because we don't think it's politically smart...but we believe that it's going to wither on the vine because we think [seniors] are going to leave it voluntarily."

On the face of it, "means-testing" Medicare sounds so reasonable.  By contrast, reforming Medicare to raise quality and contain costs would be a tough job. As I've discussed in the past, if done right, Medicare reform could serve as a model for national health care reform that included a public sector plan open to everyone. This is just what conservatives fear. 

It would be so much easier, they say, to just raise co-pays on more affluent seniors -- until finally Medicare becomes a model for nothing. At that point, those who oppose "Medicare for All" can breathe a sigh of relief.

Will the Economic Meltdown Undermine Interest in Health Care Reform?

This post originally appeared on Health Beat.

Writing on The Health Care Blog, D.C. insider Bob Laszewski puts the chances of health care reform -- at least in the form envisioned by the presidential candidates and ambitious activists -- at about zero in the wake of Wall Street's meltdown. It's easy to see why Laszewski is so pessimistic:

"On top of the $500 billion deficit [that the government faces] in 2009 ... and the cost of the Freddie and Fannie bailout ... the Congress is now being told it must take on a total of almost $1 trillion in government long-term costs to try to turn the financial system around."

That's a problem. McCain claims his reform plan will cost $10 billion; Senator Obama says his will cost $65 billion. Both are no doubt low-ball estimates. Obama's plan, for example, is more likely to cost $86 billion in 2009 and $160 billion in 2013, after it's expanded, according to the Urban Institute. Given these numbers, Laszewski says that the candidates have to "get...real" about how they're "really going to deal with health care reform in the face of all of these challenges."

In an upcoming post, Maggie will dig deeper into just how health care reformers can and should 'get real' in post-meltdown America. But instead of talking about what reformers should do, I want to discuss another important question we have to pose in the upcoming age of austerity: will the public even care about health care reform anymore, now that the economy has gone south?

On September 30, the Partnership to Fight Chronic Disease (PFCD) held a conference call with reporters. On the call were Ken Thorpe, PFCD's Executive Director, and former U.S. Secretary of Health and Human Service Tommy Thompson. Though I've never been a fan of Thompson, he had some interesting things to say.

Thompson opened by laying out the numbers behind U.S. health care expenditures, noting that "16 percent of the [U.S.] gross national product goes into healthcare [every year], and [that proportion is] on its way to 21 percent." He also pointed out that "we're spending $2.4 trillion, on the way to $4.6 trillion, and 75 to 80 percent of that cost is over chronic illnesses" like cardiovascular disease, strokes, cancer, diabetes, and obesity.

While these statistics are hardly new to health care wonks, they're worth reconsidering in light of Congress' bailout plan. Seventy-five percent of $2.4 trillion is $1.8 trillion -- meaning that, annually, chronic diseases cost us almost three times as much as the current bailout bill. The nation's total health care bill is the equivalent of passing a bailout, saving Bear Sterns, nationalizing Fannie and Freddie, and propping up AIG twice every year.

If nothing else, the Wall Street implosion puts the sheer scale of America's health care woes in perspective. As such, Thompson and Thorpe agree that the economic meltdown is a powerful wake-up call to the American public. During the call, Thompson said that he thinks that citizens are "absolutely frustrated with Congress and Washington avoiding problems," and are thus likely to begin demanding action on long-term crises like health care. The need for reform "is hung around the neck of Democrats, Republicans, George Bush and everybody else, and Wall Street," he said, and the American public wants to "find an answer." Thorpe agreed, saying that outrage surrounding the economic crisis has "stirred a bee's nest" of dissatisfaction that will "elevate the interest and desire to do something on healthcare reform in 2009."

In other words, our economic crisis highlights the danger of senseless spending and lays bare the catastrophic danger that comes with ignoring the rumbling of a financial crisis. As Thompson and Thorpe see it, voters are deciding that they're mad as hell -- and health care is another area triggering their wrath.

Dr. David Kibbe of the American Academy of Family Physicians agrees. Also writing on The Health Care Blog, Kibbe argues that Americans' feelings of betrayal over Wall Street's greed will spill over into health care. Kibbe notes: "[A]ny sentient observer of this [economic] trickery on such a massive and systematic scale will start to ask questions about who else among our highest paid and most trusted professionals might be lying to us about the well being we place in their hands.   Who else [besides financiers,] they will ask, is making money off our trust in them? Who else, they will ask, is skimming money off the top of an inflated and ultimately doomed -- because unsustainable -- market for complex services? Where is the next bubble that privatizes profits but socializes risk?"

It's health care, says Kibbe -- a sector where "fifty million people are without health insurance, and at least that many are under insured, while revenues going into the industry continue to increase at double digit rates of increase year after year." Then he asks: "How can this go on much longer?"

Under normal circumstances, the answer might be a good, long time. After all, our health care system has been dysfunctional for decades. But today Americans aren't just disappointed with the way our institutions work -- they're outraged and scared. In a Gallup poll released yesterday, 53 percent of Americans said they felt "angry" about the financial crisis, and 41 percent said they felt "afraid." Americans feel that the system has failed them -- and, as perverse as this might sound, it's that sort of disillusionment with institutions that is needed to fuel changes as far-reaching as health care reform.

Interestingly, the Gallup poll shows that more affluent Americans are the angriest. Sixty-three percent of college graduates say they have felt anger over the recent events in the financial world, compared with 50 percent of non-graduates and only 43 percent of those who have not attended college. Sixty-two percent of respondents in upper-income households with annual incomes of $60,000 or more have been angry, compared with 50 percent of those in lower-income households. This is important: it's always hardest to convince the "haves" that the system is broken, because the system is built to work best for them. But if Americans of higher socioeconomic status begin to acknowledge that an unsustainable system threatens the entire economy, institutional overhaul becomes a much more plausible political proposition.

Granted, all of these numbers refer to the financial crisis and not health care. But the assumption that worries about the economy will fuel outrage over health care isn't as far-fetched as it may sound. Polls show that concerns over the economy and health care do in fact trend together. Check out the graph below, from the Kaiser Family Foundation, which I originally posted back in January to illustrate this very point.

Moreover, public interest in health care is still high: the September 2008 Kaiser Family Foundation election tracking poll puts health care as the number three priority of all voters, and health care remains the second most commonly reported economic hardship (after paying for gas). What will happen when our long-time interest in health care is mixed with a new appreciation for government oversight and regulation, smart spending, and building system that works? Maybe, just maybe, a renewed political will for health care reform.

Admittedly, in post-meltdown America, resources will be limited. It's also true that the sort of done-in-one reform packages that reformers like to trumpet -- cover everybody! Cut costs! Improve quality! -- will probably have to be unpacked into separate initiatives. (This isn't necessarily a bad thing -- as Maggie said last week, "we shouldn't rush into providing health insurance for everyone until we're sure that we're offering Americans health care" anyway).

In the meantime, don't be too quick to assume that Americans have forgotten about health care because the economy has taken a nosedive. It may be that, as people feel increasingly insecure -- and get wise to the danger of governmental inaction -- they will want health care reform now more than ever.

Most Results of Drug Studies Never Published

Last week, the Guardian UK published a story that should be shocking -- but isn't: "More than Half of U.S. Drug Studies Never See the Light of Day." This serves as further proof -- if we needed it -- that pharmaceutical companies should not be allowed to control what doctors and patients know, and don't know, about new drugs.

The story follows below.

More than half of US drug safety studies never see the light of day
Only 43 percent of the evidence of safety and efficacy that the US Food and Drug Administration uses to approve drugs is published in scientific journals. The authors of the survey say this amounts to "scientific misconduct."

James Randerson,,Tuesday September 23 2008 10:46 BST

The results of more than half of all clinical trials that demonstrate the safety and effectiveness of new drugs are not published within five years of the drug going on the market, according to an analysis of 90 drugs approved by US regulators between 1998 and 2000.

The researchers, who traced the publication or otherwise of 909 separate clinical trials in the scientific literature, wrote that the failure of drug companies to publish the evidence relating to new medicines amounted to "scientific misconduct". They said it "harms the public good" by preventing informed decisions by doctors and patients about new medicines and by hampering future scientific work.

Sir Iain Chalmers, who is director of the James Lind Library in Oxford and a founder of the Cochrane Collaboration, a respected organization that reviews medical evidence, said that it was vital that all data on new medicines be made public.

"Patients may otherwise suffer or die unnecessarily," said Chalmers, who was not involved in the work. "The people who participate in a trial have a right to expect that their participation and their data will be made available publicly so that people can take whatever decisions seem appropriate in the light of that information."

The US researchers who carried out the study searched the academic literature for publication of the trials that drug companies relied on to convince the US Food and Drug Administration that their new products were safe and effective and so worthy of market approval.

Information that is used to convince the regulators is not necessarily subsequently published for public and scientific scrutiny, but the scale of the missing information was found to be vast.

Five years after each of the 90 drugs was first available for patients, only 43 percent of the studies supporting the drugs' use had been published, with most publication happening in the first one or two years. In the case of one product -- an antibiotic -- the researchers could not find a single supporting trial in the scientific literature, while five trials were published twice and one was published three times.

The team also found evidence for a "publication bias." Trials with statistically significant results were more likely to be published than those with non-significant results, as were those with larger sample sizes.

"In the years immediately following FDA approval that are most relevant to public health, there exists incomplete and selective publication of trials supporting approved new drugs," Prof Ida Sim and her colleagues at the University of California, San Francisco, wrote in the journal PLoS Medicine.

One possible explanation for the scientific data not being published is that drug companies hold back publication of the results that are least flattering to their new drugs. Another possibility is that academic journal editors are less inclined to publish papers on trials that have negative or ambiguous results.

"Regardless of the cause, publication bias harms the public good by impairing the ability of clinicians and patients to make informed clinical decisions, and the ability of scientists to design safer and more efficient trials based on past findings," the authors wrote. "Publication bias can thus be considered a form of scientific misconduct."

The reporting of clinical trial results should have improved since the period analysed by the researchers, because the 2007 FDA Amendments Act mandated basic results reporting for all trials supporting FDA-approved drugs and devices. However, the researchers said it remained to be seen whether clinical reporting would improve.

The new law could even have the opposite effect. "Might sponsors feel less compelled to publish equivocal trials because the basic results will already be in the public domain?" they speculated.

Liked this story? Find more health news at Health Beat.

Universal Health Coverage Is No Silver Bullet

The Massachusetts experiment in health care reform is all about expanding access. But it doesn't try to control costs. This, in a nutshell, is why it's running into trouble.

The plan didn't reform health care delivery, just coverage. Granted, in terms of bringing more people in under the tent, it's been a success: Since the plan went into effect in 2006, 439,000 people have signed up for insurance -- a number that represents more than two-thirds of the estimated 600,000 people uninsured in the state two years ago. This surge in coverage has reduced use of emergency rooms for routine care by 37 percent, which has saved the state about $68 million. (Going to the ER for routine care drives up health care costs by creating longer wait times and tying up resources that can be used to help patients who are critically ill).

But even with these savings, Massachusetts is having trouble funding its plan. Earlier this month the Boston Globe reported that the governor's office is planning to shift more responsibility for funding to employers. Currently, the Mass. Health care law requires most employers with more than 10 full-time employees to offer health coverage or to pay an annual 'fair share' penalty of $295 per worker: this is called 'pay or play', an employer either provides coverage or pays a fee toward the system for not doing so.

To "play" rather than "pay," employers must show either that they are paying at least 33 percent of their full-time workers' premiums within the first 90 days of employment, or that they are making sure that at least 25 percent of their full-time workers are covered on the company's plan. (In other words, they must be paying a large enough share of the premiums so that 25 percent of their employees can afford the plan they offer.)

Now, instead of giving employers this Either/Or option, the new proposal requires that employers do both -- or fork over the penalty fee. In a sense, this is an admirable move by the government, since its intention is to push toward truly universal coverage. But there's also a game of scrounging-for-dollars going on here: The state wants employers to pay more -- to, in the words of Mass. Governor Deval Patrick, "step up" and embrace "shared responsibility" -- either by covering a greater share of health care costs or paying more in penalty fees.

As you might expect, businesses are putting up a fight. They say that Patrick's proposal "ignores the obvious," which is the fact that "employers definitely are doing their part." While it's tempting to vilify "Big Employer" as stingy and selfish, the truth is that there's only so much you can ask businesses to do without harming citizens.

As I pointed out in a March blog post, research shows that there's a big trade-off between health care costs and workers wages: when employers have to pay a lot for health care, they take the cost out of employees' paychecks. Or, as a 2004 study from the International Journal of Health Care Finance and Economics put it, "the amount of earnings a worker must give up for gaining health insurance is roughly equal to the amount an employer must pay for such coverage."

In other words, you can't bleed employers dry without also screwing workers. True, big corporations might have deep enough pockets to pay more for health care without adjusting workers' wages. But they're still bottom-line driven enterprises, which means that they're going to try and break even wherever possible. Unless you want to see laws that strictly regulate the correlation between business health care costs and workers' wages, the working Joe's income is going to take a hit as employers shoulder more health care costs.

The other choice employers have is to opt out of coverage and instead pay the penalty. Many have pointed out that, for employers, this is an attractive option -- particularly in Massachusetts, which, as of 2007, had the highest annual health care costs per employee in the country: $9,304. That's a lot more than $295 a year. We can be certain that this fee will rise in the future. And once it gets high enough for employers to choose health coverage over the fee, they're still going to take the cost of that coverage out of workers' wages.

On the one hand, one might argue that this is fair -- that workers are better off with health insurance rather than higher salaries. Massachusetts is a relatively wealthy state: in 2008, median income for a family of four stood a $85,420 (so half of the population earned more than that). Insofar as some of Massachusetts' wealthier citizens don't have health insurance, it probably would make sense for them to earn a little less, and be covered. Some would insist that this should be an individual choice, but the truth is, if an individual decides to go without insurance, we all wind up paying the cost when he or she becomes seriously ill. On the other hand, many households could not afford to take a pay cut -- especially when you consider the cost of housing in Massachusetts.

Ultimately, the only way to make a universal health care system sustainable both for employers and employees is to tackle the high cost of health care in Massachusetts. As noted, in the Commonwealth, the average annual premium for an employee's health care is $9,304 -- significantly more than the national average of $6,881.

As Maggie has pointed out in the past, this is not because insurers in Massachusetts are profiteering. Insurance is expensive in the Commonwealth because its citizens consume more health care than people in many other states. They undergo more tests and procedures than most of us, and they see more specialists. Look at a graph of average health care expenditures per person in Massachusetts compared to average health care expenditures in the rest of the U.S., and you find that in Massachusetts, individuals receive an average of nearly $10,000 worth of care each year -- compared to just a little over $7,000 per capita nationwide.

High consumption of care is driven, Maggie explained,"by the fact that the state is a medical Mecca, crowded with academic medical centers, specialists and the equipment needed to perform any test the human mind is capable of inventing."

As she originally explained in this article, in states where there are more hospital beds and more specialists, the population receives more aggressive, more intensive, and more expensive care. Even after adjusting for local prices, race, age, and the underlying health of the population, supply drives demand. And it turns out that the Bay State has one doctor for every 267 citizens -- versus one doctor for every 425 people in the nation as a whole. Meanwhile, the state boasts an abundance of specialists, while suffering a critical shortage of primary care physicians.

For reform to work in Massachusetts, the state needs to make care more cost-effective, not just more accessible. That means encouraging providers to emphasize proven treatments that can do the most good for the most people which avoiding over-priced, not fully proven bleeding edge services and products.

This won't be easy. As Ezra Klein recently pointed out on his blog at The American Prospect: "people generally like to equate better health with awesomer technology, but developing a slightly better drug for late-stage cancer -- a good, profitable innovation -- will do much less for health than getting the flu vaccine to everyone who needs it, or creating systems so everyone with elevated cardiac risk is on statins. These interventions are low innovation, but actually extremely effective ... Saving some level of money on innovation in order to rechannel it to access and basic interventions would probably make the country a whole lot healthier. But I don't think you're allowed to say that." Yet if health care is to improve -- in both Massachusetts and the U.S. -- this is exactly what we need to say.

In fact, Massachusetts is a classic example of the technology-cost problem. According to a Boston Globe report, between 1997 and 2004, the number of MRI scanners in Mass. tripled to 145, about the total for all of Canada. From 1998 to 2002, the number of patient MRI scans in the state increased by 80 percent, to almost 500,000 a year. With insurers paying between $500 and $1,400 to cover a scan, the numbers add up: in 2003, Harvard Pilgrim, a non-profit insurer, shelled out $73 million on MRI scans, even as other costs increased as well. It should come as no surprise that a state with so much medical technology, also has more medical and clinical lab technicians than any state in the union: 184.06 per 1,000 of the population, almost twice the national average of 101.32.

Massachusetts also reports an abundance of hospital beds -- enough to allow patients to spend an average of 11.8 days in the hospital during their last six months of life -- compared to 9.5 days in Maine. None of this is consciously planned. It's just that if the beds are available, it's easier to hospitalize the patient. And once they are in the hospital, it's easy to refer them to a dozen specialists, assuming that enough specialists are available.

Bottom line, health care in Massachusetts is extremely expensive, thanks to supply-side factors -- which means expanding and sustaining full coverage is, fiscally speaking, a tough proposition. Luckily, steps are being taken to address cost issues: in June, the state's biggest insurer and the state itself said that they would stop reimbursing doctors and hospitals for 28 medical errors.

Certainly punishing doctors isn't the key to sustainable health reform -- and some errors are more "preventable" than others. But changing health care delivery -- that is, changing patterns in the types and volume of treatments and procedures made available to patients -- is the key to making health care run smoothly in the long-term. Universal coverage is wonderful and necessary. But it's only one piece of the health care puzzle.

Want High-Quality Universal Health Coverage? Fix Medicare First and Use It as a Model

This article originally appeared on Health Beat.

Thanks to the unbridled rise in health care prices, Medicare is going broke. As I mentioned in a recent post, four years ago the Medicare trust fund that pays for hospital stays started to run out of money. In 2004 the fund began paying out more than it takes in through payroll taxes.

"Since then, the balance in the fund, combined with interest income on that balance, has kept the fund solvent. But in just 11 years, it will be exhausted," the Medicare Payment Advisory Commission (MedPac) reported in March. "Revenues from payroll taxes collected in that year will cover only 79 percent of projected benefit expenditures." And each year after 2019, the shortfall will grow larger.

Make no mistake: This is not an example of an inefficient government program spending hand over fist without caring whether it is getting a bang for the taxpayer's buck. As I discussed in that earlier post, health care prices have been climbing -- without a concomitant improvement in patient outcomes or patient satisfaction -- in the private sector as well.

Medicare Reform Could Pave the Way for National Reform

Before trying to roll out national health insurance, the next administration needs to address the structural problems that undermine the laissez-faire chaos that we euphemistically refer to as our health care "system." Otherwise, we run the risk of winding up with a larger version of the dysfunctional, unsustainable system that we have today. Ideally, the administration should make Medicare reform a demonstration project for high-quality, affordable universal coverage.

Let me be clear: Medicare reform does not preclude national health reform. To the contrary, by starting with Medicare and showing what can be done, reformers enhance their chances of winning the larger war.

Nor does focusing on Medicare first mean that the suffering of uninsured and underinsured Americans must be ignored. As part of Medicare reform, Medicaid and the State Children's Health Insurance Program should be folded into Medicare, turning these "poor programs for the poor" into federal programs, expanding coverage and raising the fees for doctors who treat Medicaid patients.

Medicare presents reformers with a promising starting point. Politically, Medicare reform will be easier than a nationwide overhaul, simply because Congress recognizes that when it comes to Medicare, it has no choice. Legislators know that Medicare has reached a tipping point: They must do something.

This is why, earlier this month, the Senate flirted with political suicide by considering letting a scheduled cut in the fees Medicare pays physicians go into effect. On July 1, Medicare was supposed to slash physicians' fees, across the board, by an average of 10.6 percent. Physicians threatened that they would close their doors to Medicare patients. At the eleventh hour, legislators stepped back from the edge of the cliff.

But Congress knows that the problem has not been solved. Legislators will have to revisit the problem of Medicare spending early in 2009. Physicians' fees are scheduled for another across-the-board cut on Jan. 1, 2009. Everyone knows that this is a crude solution. Medicare pays primary care physicians too little, which is why, MedPac explains, 30 percent of Medicare patients looking for a new primary care doctor report difficulty finding one. Meanwhile, Medicare overpays other physicians for certain services. Dollars need to be redistributed; the net result could easily be a wash.

How Medicare Can Save Dollars and Lift the Quality of Care

But Medicare cannot contain runaway inflation simply by looking at how much it pays doctors. The program overpays drugmakers; it overpays device makers; it overpays private insurers who offer Medicare Advantage. In some cases, it overpays hospitals -- or squanders dollars on services that don't benefit patients, without giving hospitals the right financial incentives to provide more effective, safer care.

In its March and June reports, the Medicare Payment Commission has made a number of shrewd and imaginative suggestions for cutting waste in the system. First, Medicare should eliminate the windfall bonuses that it now pays Medical Advantage insurers (see "The Problems With Medicare Advantage").

Secondly, MedPac details ways that Medicare can begin to pay doctors and hospitals for the quality of the care they provide rather than the quantity. I'll be writing more about this in future posts.

MedPac also calls for an independent, unbiased, "comparative effectiveness institute" that would compare new, cutting-edge drugs, devices and procedures to the less expensive products and treatments that they are trying to replace. Medicare would then make coverage decisions based not on the cost of these treatments, but on their effectiveness, paying for the treatments that are most effective for a particular set of patients. (This would not be one-size-fits-all medicine).

The U.K. offers a model: The National Institute for Health and Clinical Excellence (NICE) reviews medical research, decides which treatments to cover and issues guidelines to doctors. (Note: Since the U.K. has a much, much smaller health care budget, NICE must look at the cost-effectiveness of treatments, i.e., it must find out if a product that is likely to give the patient only another six months of life is worth the price tag. But as I have written, because we have so much long-hanging fruit in our bloated system, we can save billions just by concentrating on clinical effectiveness, without worrying about cost-effectiveness.)

In the U.K., NICE uses its research to issue guidelines for "best practice" to physicians. Note that there are not "rules," but guidelines. Everyone understands that in individual cases, physicians might want to deviate from the recommendations. But in the U.K., physicians now follow the guidelines 89 percent of the time.

Medicare also could reap huge savings by repealing that part of the Medicare bill -- negotiated behind closed doors at the end of 2003 -- that specifically prohibits Medicare from negotiating with drugmakers for the bulk discounts that the Veterans Administration wins. As a result, Medicare now forks over at least 50 percent more than the VA pays for half of the top 20 brand-name prescription drugs sold to seniors.

Won't industry lobbyists fight tooth and nail against such changes?

Absolutely. The for-profit health care industry reaps a handsome profit from sky-high spending.

Yet, despite the opposition, when it comes to Medicare reform, legislators have a compelling argument: Neither the elderly nor the taxpayers who support Medicare can afford to continue to be gouged by drugmakers, device makers and others in the health care industry who are the "price makers," while patients and taxpayers have become what Wall Street calls the "price takers."

Today, the health care industry says: "We will charge whatever the market will bear." That sounds fair enough. But when "the market" is comprised of seriously ill patients (and roughly 80 percent of our health care dollars are spent on those who are seriously ill), it turns out that there is almost no limit to what "the market" will bear. This is why free market competition in health care doesn't work the way it does in other sectors of the economy: When it comes to health care, the customer has too little leverage.

Meanwhile, in the unregulated Wild West that we call a health care system, no one pushes back to protect the patient. Virtually every other developed country in the world negotiates for bulk discounts on drugs. We don't. Other countries insist on unbiased evidence that a new, more expensive product or procedures is, in fact, more effective than less expensive treatments already available. We don't. (The FDA only requires that a sponsor provides evidence that the new entry is more effective than a placebo -- in other words, better than nothing.)

Most Americans would agree: The government needs to defend both the elderly and taxpayers. We simply cannot afford to keep the pharmaceutical industry's shareholders in the style to which they have become accustomed. (Until recently, drugmakers have been far more profitable than virtually any other Fortune 500 businesses. From 1995 to 2002 they took first prize, reporting earnings that ranged from 13 percent to 18.6 percent of sales each and every year. Over the same span, the average Fortune 500 firm posted earnings that averaged just 3.1 percent to 5 percent of revenues. Granted, in 2004, drugmakers fell to third place, trailing mining, crude oil production and commercial banks, but even then, earnings equaled 16 percent of sales.)

Medicare Reform Is a More Manageable Project

A final reason to begin Medicare reform before tackling national health care reform is that, when compared to a fragmented national health care system that involves a kaleidoscopic cast of payers and insurers, Medicare is a single and fairly coherent program. This is a more manageable project. It will give reformers a chance to show that they can, in fact, trim spending while lifting quality. This should provide a blueprint for tackling the larger, messier job of overhauling care nationwide.

If done right, national health care reform will take time. Those fighting for universal coverage should not delude themselves: Reform will be extraordinarily difficult, not only because the system is so fragmented, but because conservatives and progressives are so polarized on this issue. The political climate is even more fraught than it was when the Clintons attempted reform in 1993.

In 1993, compromise seemed possible. Keep in mind, 23 Republicans, including then-Minority Leader Robert Dole, co-sponsored a bill introduced by Republican Sen. John Chafee that sought to achieve universal coverage through a mandate that would require that all individuals buy insurance.

Today, where would you find 23 Republicans willing to support progressive reform that doesn't simply hand the keys to the kingdom to the private insurance industry?

In 2008, progressives and conservatives are so polarized on this issue that anyone who talks about "bipartisan compromise" is talking about health care "reform" in name only. Conservatives believe that free market competition can solve our health care problems. Progressives understand that this is a sector where market competition doesn't work to ensure high quality and reasonable costs. Government oversight is needed to ensure that insurers do not discriminate against those who are sick, and that everyone receives an equally comprehensive package of benefits at a price they can afford.

Conceivably, if Congress is in a hurry, it could cobble together compromise legislation that gives every American access to a piece of paper called "health insurance." But this would not mean that middle-class Americans would have access to health care. If the insurance industry is not regulated, insurers will continue to sell health care policies that are filled with holes, while shifting costs to the sickest patients.

Finally, the most important reason why the next administration should put Medicare first on its health care list is this: If Washington tackles Medicare reform in 2009, it can show Americans that it is possible to reduce costs and improve care. In fact, lower costs and higher quality go hand in hand.

This is counter-intuitive. The notion that more care -- and more expensive care -- is not better goes against some of our most deeply held assumptions about medicine and medical technology. But as I have explained, decades of medical research show that less aggressive, less intensive care leads to better outcomes.

Until most Americans understand this, it will be supremely difficult to create an efficient, affordable and sustainable system that offers high-quality care to all. This is why starting with Medicare reform could lead to the health care reform that Americans need.

How Long Will Your Doctor Continue Accepting Private Insurance?

This article originally appeared on Health Beat.

More and more doctors are fed up with private insurers. It's not just a question of how stingy they are, but how difficult it is to get reimbursed. Paperwork, phone calls, insurers who play games by deliberately making reimbursement forms difficult to interpret ...

Some physicians have just said "no" to insurers.

What does this mean for patients? Business models vary. Some doctors charge by the minute. I recently read about a physician who punches a time clock when the appointment begins. She has calculated that her time is worth $2 per minute. Fifty-nine minutes = $118. Will you be paying cash, or by charge today? Somehow, I think the meter would make me nervous. I suspect I might begin talking very quickly. But this is only one model.

Rather than charging by the minute, some doctors make fee-for-service charges. In those cases, many physicians mark up their fees well beyond what an insurer would pay. But, they point out, they also spend more time with their patients. No one feels rushed.

A story in a New Jersey newspaper describes how physicians in Northern Jersey have begun following in the footsteps of "elite Manhattan doctors and are withdrawing from all insurance plans." The article compares fees with and without insurance. On the right, the fees that insurers typically pay for these services; on the left, the fees that Jersey doctors who don't take insurance charge:

  • Mastectomy: $5,000 / $900

  • Ruptured abdominal aneurysm: $8,000 / $1,800

  • Routine screening mammogram: $350 / $100

  • Initial neurological consultation: $400 / $100

Some Doctors Share Savings with Patients

Other physicians find that if they don't take insurance, they can cut their overhead and actually charge patients less.

Over at Revolution Health, "Dr. Val and the Voice of Reason" tells how Dr. Alan Dappen has set up his practice:

"He is available to his patients 24 hours a day, 7 days a week, by phone, e-mail and in person. Visits may be scheduled on the same day if needed, prescriptions may be refilled any time without an office visit, he makes house calls, and all records are kept private and digital on a hard drive in his office.

"How much do you think this costs? Would you believe only about $300/year?"

Dappen has streamlined his practice. It's not just that he doesn't need an assistant to keep up with stacks of insurance paperwork. In general, he keeps his overhead low, offers full price transparency, has "physician extenders" who work with him, and "charges people for his time, not for a complex menu of tests and procedures."

The key is that Dappen practices very conservative medicine.

"I believe in doing what is necessary and not doing what is not necessary," he says. "The health care system is broken because it has perverse incentives, complicated reimbursement strategies, and cuts the patient out of the billing process. When patients don't care what something costs, and believe that everything should be free, doctors will charge as much as they can. Third-party payers use medical records to deny coverage to patients, collectively bargain for lower reimbursement, and set arbitrary fees that reward tests and procedures. This creates a bizarre positive feedback loop that results in a feeding frenzy of billing and unnecessary charges, tests and procedures. Unlike any other sector, more competition actually drives up costs."

Dappen has it right about competition in the health care marketplace. Studies show that in areas where there are more hospitals competing with each other, hospital bills are higher. This is in part because hospitals jousting for market share all invest the same cutting-edge equipment. The only way to pay for it is to use it. So they do more tests and more procedures, driving hospital bills higher.

Dappen, who practices in Fairfax, Va., told Dr. Val Jones that "after building a successful traditional family medicine practice he felt morally compelled to cease accepting insurance so that he could be free to practice good medicine without having to figure out how to get paid for it. He noticed that at least 50 percent of office visits were not necessary -- and issues could be handled by phone in those cases. Phone interviews, of course, were not reimbursable by insurance."

Dappen also casts a skeptical eye on the pricey annual physical: "The physical exam is a straw man for reimbursement. Doctors require people to appear in person at their offices so that they can bill for the time spent caring for them. But for long-standing adult patients, the physical exam rarely changes medical management of their condition. It simply allows physicians to be reimbursed for their time."

Again, Dappen is spot on.

"Cutting the middleman (health insurance) out of the equation allows me to give patients what they need without wasting their time in unnecessary in-person visits," Dappen explains. "This also frees up my schedule so that I can spend more time with those who really do need an in-person visit."

How many readers have found themselves sitting in a doctor's waiting room, not because they were sick, but because they needed to renew a prescription? Since insurers don't pay doctors for the time it takes to read an e-mail or to take a phone call and then write a new prescription, many doctors insist that patients come in whenever they need a renewal -- that way, the doctor can bill the insurer. This makes sense if the doctor needs to check your blood pressure to see whether the medication is working. But if he's simply going to chat for a few minutes and write the script, the visit is a waste of time.

"Health insurance is certainly necessary to guard against financially catastrophic illness. And the poor need a safety net beyond what Dr. Dappen can provide," Jones observes. "But for routine care," a practice like Dappen's "can make heath care affordable to the middle class, and reduces costs by at least 50 percent while dramatically increasing convenience."

Concierge Medicine

Dr. Val calls Dappen's practice "concierge medicine for the masses." Other physicians practice more traditional "concierge medicine:" customized, round-the-clock care for the elite.

In California, the Ventura County Star reports that local doctors opting out of insurance "spend more time with patients -- and make more money."

Some doctors charge patients an annual "membership fee" -- rather like the fee you might pay to belong to a country club.

"I wish I had done it a long time ago," says Dr. Edward Portnoy. An internist, Portnoy once had a practice of about 2,800 patients. Now he sees roughly 380 people but takes home "about the same profit" thanks to the $1,800 membership fee that each patient pays yearly.

Portnoy spends roughly twice as much time with each patient as he did when he accepted insurance. He explains that he has "more time to do intensive physicals and help patients stay healthy, rather than running from one crisis to the next like a war surgeon doing meatball surgery."

At Dr. Stanley Frochtzwajg's family practice in Ventura, patients don't face annual fees but pay "at the office for whatever services they receive," the paper observes. "A routine office visit is about $80." Patients are then given the paperwork to submit to their insurance companies themselves. "One patient said she ends up paying about 30 percent of the bill but is happy with her care and willing to pay for it."

The paper reports that doctors "don't really like the term 'concierge' or 'boutique' medicine. They prefer labels like personalized, preventive care."

That's understandable; they don't want to sound snobbish. But in truth: "There's not a lot of people who can afford it," says Anthony Wright, executive director of the consumer advocacy group Health Access California. "The reason some people call it boutique medicine is that this is for a well-to-do clientele."

Wright is concerned: "I don't think systems that shift more burden onto the patients are the answer to our broken system or will evolve into more than an isolated alternative. ... The trend of boutique medicine sends the consumers in the direction of you're on your own. Everyone for themselves."

On the other hand, the paper notes, "Carol Miller of Thousand Oaks thinks the $3,600 she and her husband pay in annual fees to see Portnoy is worth it because it brings peace of mind. The money covers an annual physical and a battery of screenings for everything from Alzheimer's to sleep apnea. The fee also covers follow-up that focuses on preventive care.

"There are other perks. People in Portnoy's waiting room find a basket filled with Cliff bars, crunchy peanut butter and chocolate chip bars. Tea and Snapple is served."

Crunchy peanut butter and chocolate chip bars? Is this part of the emphasis on preventive care?

Some worry about what the larger trend means. Are the Millers, who receive an annual "battery of screenings," being overtreated? If insurers reimburse for even 70 percent of unnecessary treatment, are we all paying for boutique medicine?

Dr. Bob Gonzalez, medical director at Ventura County Medical Center, also talked to the reporter and confided that he worries "that less reliance on insurance means fewer people getting health care. They won't be able to afford it."

The specter of more doctors downsizing their practices and seeing fewer patients also alarms Gonzalez. It means patients won't be able to find any doctors, or they could be dumped on an already overburdened doctor.

So yes, he said, more money, less insurance and more time with patients may be good for individual doctors.

"But whether it's good for society or good for patients is the overall question."

Congress Passes Key Medicare Bill

This article originally appeared on Health Beat.

When Ted Kennedy came onto the Senate floor, his colleagues cheered.

He was there to vote on the bill that would prevent a 10.6 percent cut to physicians who treat Medicare patients.

Just before Congress broke for the July 4 holiday, the bill missed the 60 votes needed to pass by just one vote.

Today, Kennedy, who is battling a brain tumor, brought that vote to the Senate floor. "Aye," the 76-year-old Kennedy said, grinning and making a thumbs-up gesture as he registered his vote.

Meanwhile, it appeared that Republican members of the Senate had been released to vote as they wished after it became apparent that the 60-vote threshold would be met. Pressure from seniors, the AARP , and the AMA had been mounting on members who voted against the bill June 26.

Republicans resisted voting for the legislation because while it spares physicians, it would reduce the fat subsidy that Congress has been giving private insurers who offer Medicare Advantage. President Bush and Senate Republicans had been strongly against any cut in the Advantage program.

In the end, the vote was 69 to 30 in favor of the bill. President Bush had threatened to veto the bill if it passed the Senate, but 67 votes make it veto-proof. And since the House has already voted 355-59 in favor of the bill, Congress appears able to over-ride any veto.

According to Roll Call, 18 Republicans broke with their party to pass the House-backed bill.

Sighs of relief could be heard on the Democratic side as lawmakers, beginning with Sen. Kay Bailey Hutchison (R-Texas), chairwoman of the Republican Steering Committee, joined with Democrats to pass the bill. Hutchison's Texas colleague, Sen. John Cornyn (R), who was on the receiving end of an American Medical Association ad blitz slamming his pre-recess position, also ended up voting for the bill.

Other Republicans who voted to proceed to debate on the politically charged bill included Sens. Elizabeth Dole (N.C.), George Voinovich (Ohio), Susan Collins (Maine), Norm Coleman (Minn.), Pat Roberts (Kan.) Gordon Smith (Ore.), Lisa Murkowski (Alaska), Bob Corker (Tenn.), Johnny Isakson (Ga.), Arlen Specter (Pa.) and Mel Martinez (Fla.).

McCain did not appear.

McCain's Predicament

Today, Bloomberg News did an excellent job of explaining why McCain might not show up:

"Senator John McCain will be on the spot, in person or by his absence, when the Senate takes up a measure today to halt a cut in Medicare payments to doctors.

"Republicans have stalled Democratic-backed legislation to reverse the 10.6 percent cut in doctors' fees by reducing payments to insurance companies instead. Democrats on June 26 fell one senator short of the 60 they will need to force a floor vote. Two senators were absent: Edward Kennedy, a Democrat from Massachusetts who is being treated for brain cancer, and McCain of Arizona, the presumptive Republican presidential nominee.

"For McCain, whose schedule indicates he will campaign today in Pennsylvania and Ohio and whose office won't say whether he'll show up in the Senate, the vote is a political dilemma. "

"In one case McCain could be voting against his party and in the other he could be voting against an issue framed as pro-senior and pro-physician,'' Robert Blendon, a health policy professor at Harvard University's School of Public Health in Boston, said in a telephone interview yesterday."

It is worth noting that McCain is one of few Republican senators who voted against the original legislation that created Medicare Advantage and provided what many view as windfall subsidies for private insurers.

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