With or Without Health Care Reform, We’re Screwed

Wikipedia is “the free encyclopedia that anyone can edit.”

It’s also a resource many American doctors use to find medical information.

According to a survey of 1,900 physicians by Manhattan Research, a health care market research firm, nearly half of doctors going online for professional purposes reported using Wikipedia as a source of medical information. That number has doubled in the past year alone.

The threat is obvious. Can you imagine your doctor stepping out from the exam room, tapping away at his or her computer seeking the advice of Wikipedia? Research has documented the danger. A study from The Annals of Pharmacotherapy compared drug information from Wikipedia with the Medscape Drug Reference, a resource whose information is reviewed by pharmacists. Researchers found that Wikipedia omitted important information, including drug side effects. Another entry overlooked a commonly prescribed pain medication’s association with miscarriages.

Forget the debate over single payer health care.  Forget the talk about a public option.  Quality health care is a pipe dream if doctors are cheap, stupid, or lazy enough to rely on a nonauthoritative, easily vandalized resource like Wikipedia for health information.

July 20, 2009 · Filed Under Health care

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Mandating Late-Term Abortion Training for OB/GYNs?

A few months ago, I wrote about the movement to apply a pro-choice litmus test to OB/GYN residency applicants.  The theory is that there aren’t enough doctors willing to perform abortions because Americans are too tolerant of conscientious objection in the medical field.  Conscience protections ought to be thrown out the window to make way for practitioners who are more accommodating of women seeking to terminate their pregnancies.

This week, following the assassination of late-term abortion provider Dr. George Tiller, comes the disturbing suggestion from Hilzoy (via Megan McArdle) that we “[r]equire training in late-term abortion techniques for Ob/Gyn certification.” The idea is to mitigate the risk of violent action against late-term abortion doctors by increasing their numbers, “ensuring that no one person has to take on him- or herself the risks that militant anti-abortionists want to subject them to.”

Hey, while we’re at it, why not launch an Inquisition to purge pro-life doctors from the medical profession?

It’s essential that we continue to train doctors who identify as pro-life, as well as those who are passionately pro-choice.  Here’s what I wrote in my original piece on the subject:

A woman should be able to choose a doctor whose moral compass points in the same direction as hers. Families should know that their doctor shares their values and will remain faithful to them, especially in a life or death situation.  Revoking conscience protections would revoke patient choice, a violation that would offend more pro-choice liberals if they were, at the very least, concerned with being consistent.

Most liberal feminists would balk at receiving gynecological care from a dedicated pro-lifer.  Shouldn’t pro-life women be able to choose a doctor who doesn’t engage in professional practices they find morally objectionable?

There is, without a doubt, a demand for abortion providers in America.  There is also a demand for doctors whose work is informed by a pro-life perspective on abortion, contraception, sterilization, and end-of-life decisions.  It is not the government’s role to decide that one of these categories of professionals should be phased out because it is less valuable than the other.

When did it become acceptable to ask the government to facilitate the subordination of a pro-life patient’s dignity to a pro-choice patient’s dignity?

Mandating that OB/GYNs be able to provide late-term abortions would be a frightening assault on patient choice and dignity.  It’s doubtful that it would save the lives of abortion doctors, but it would most certainly leave millions of pro-life women (and the many pro-choice women who find late-term abortions appalling) without access to medical care that meets their psychological and moral needs.

June 3, 2009 · Filed Under Abortion, Health care, Liberal Absurdity, Women

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Will Health Care Reform Spawn the Next Great Culture War?

When I turn 35 I will have my first mammogram.

In the United States, mammography is recommended for breast cancer screening every one to two years beginning at age 40.  The best available evidence suggests that mammography screening among women aged 40 to 74 reduces breast cancer mortality.

But due to a few minor risk factors, three doctors have suggested I undergo a baseline mammogram at 35. I’m not thrilled with the idea of having a technician I’ve never met manipulate my breasts into squishing position, but being felt up and flattened out sounds a lot better than being dead, so I’ll take my chances.

Of women who receive annual screening mammography beginning at age 40, six out of 10,000 over a decade will have their lives saved.  Breast cancer will be detected and cured in many more, but regular mammograms will only make a life or death difference for six of every 10,000 women in that group.  Mammograms are of extremely high value to those women and their families, but don’t offer much bang for the buck when it comes to the other 9,994 women.

And wringing more bang from every health care buck is reason enough for Canadian and British recommendations that women wait until age 50 to begin receiving screening mammographies.  In these countries where cost-effectiveness studies influence health policy and medical practice, six saved lives aren’t worth the substantial costs associated with all those extra mammograms and the false positives they sometimes produce.

Canadian women are offered routine mammograms every two years, but only from age 50-69 because “evidence is not conclusive” that routine mammograms benefit younger and older women.  Doctors have some leeway with regard to high risk patients.

In the United Kingdom, mammograms are recommended every three years beginning some time between age 50 and 53.  Based on guidelines developed by the Orwellian-named NICE (National Institute for Clinical Excellence), the National Health Service insists that for women under 40, “mammograms should only be used as part of clinical trials into screening and that they shouldn’t be used under age 30 at all.”  According to NICE, “Healthcare professionals should respond to women who present with concerns but should not, in most instances, actively seek to identify women with a family history of breast cancer.”

It is hardly shocking that the breast cancer mortality is 9 percent higher in Canada and 88 percent higher in the United Kingdom.  Nine of 10 middle-aged American women (89 percent) have had a mammogram, compared to less than three-fourths of Canadians (72 percent).  And British and Canadian patients wait for care about twice as long as Americans.

There are indeed valid criticisms American health care, but one area in which we excel is that we don’t base guidelines for care on cost-utility analysis. That’s why the U.S. ranks first in providing the “right care” for a given condition and has the best survival rate for breast cancer.

Obamacare may force Americans to give up those bragging rights.

The “right care” may soon be defined in part by how much that care costs. Health care reformers acknowledge the impossibility of implementing universal health care without introducing cost containment measures, and Democrats are enamored with a method used by the British called “comparative effectiveness research” (CER.)

AARP CEO and CER proponent Bill Novelli describes comparative effectiveness research as “a wonky term that just means giving doctors and patients the ability to compare different kinds of treatments to find out which one works best for which patient.”  And at its best, that’s just what CER does.  CER is not inherently bad.  For example, it can help doctors cut through seductive pharmaceutical advertising to identify older, less commonly prescribed drugs that are just as effective as newer, more expensive ones.

But with CER, the devil is in the details.

CER can lead to one-size-fits-all medicine and encourages a purely analytical approach to care that is not always beneficial to the patient. The mythical average patient overshadows the individual patient, leaving most of us with about as many options as a public school cafeteria at lunchtime.

And in the UK, NICE includes cost as a determining factor in the comparative effectiveness studies that inform clinical guidelines.  Determinations about whether citizens will have access to drugs, tests, and procedures are based on cost per quality of life year (QALY.)

The QALY score is a fairly crude metric that takes into account both the number and quality of years a medical intervention is expected to add to a patient’s life.  Here’s the upshot of using QALYs to determine cost effectiveness:

On the QALY scale, 0 means you’re dead, 1 means you’re in perfect health, and varying levels of debility fall in between. Imagine two groups of people, one with a QALY of 1 and the other with a score of 0.5. An expensive technology brings a year of life to both groups. But in the second, that technology would be counted as having provided only six months, and thus be twice as expensive. It may be deemed too costly for that patient group.

The older you are, the sicker you are, the more disabled you are, the less cost effective it is to treat you.  And if the cost per QALY of a medical intervention you need exceeds £20-30,000 (around $32,000 – 48,000), you’re out of luck.  Drugs, particularly end-of-life treatments, are routinely rejected for use due to poor cost-effectiveness.  And screening tests, like the mammograms American women take for granted, are severely restricted to ensure expenditures remain under the cost per QALY threshold.

Liberal proponents of health care reform accuse conservatives of paranoia and fear mongering about health care rationing.  Critics of CER are demonized as extremist spewers of far right talking points who don’t care about improving clinical effectiveness.  Surely a uniquely American flavor of a CER board would never become as proscriptive as NICE.

But it seems conservative anxiety (and perhaps a bit of healthy paranoia) is more than warranted by Washington Democrats singing the praises of cost-cutting comparative effectiveness studies.  Bear with me while I review some of the health care rationing talk in CER clothing coming from inside the beltway.

The stage for CER to become a significant component of health care reform was set when President Obama’s stimulus bill passed with a $1.1 billion appropriation for CER.  In April, Senate Minority Whip Jon Kyl (R-AZ) introduced a budget amendment to ensure that CER would be used appropriately:

Statement of Purpose:
To protect all patients by prohibiting the use of data obtained from comparative effectiveness research to deny coverage of items or services under Federal health care programs and to ensure that comparative effectiveness research accounts for advancements in genomics and personalized medicine, the unique needs of health disparity populations, and differences in the treatment response and the treatment preferences of patients.

The amendment was defeated 54-44.

Last week, members of the New Democrat Coalition proposed HR 2505, a bill to establish a new government bureaucracy called the Health Care Comparative Effectiveness Research Institute.  The Institute would prioritize research based on both clinical and economic factors, including “the effect or potential for an effect on health expenditures associated with a health condition or the use of a particular medical treatment, service, or item.”  This would not be a problem if there were safeguards to ensure that best practices are not interpreted to mean the least expensive practices.

Officials at National Institutes of Health (NIH) recently announced a stimulus-funded initiative to integrate cost-effectiveness into clinical research.   “Cost-effectiveness research will provide accurate and objective information to guide future policies that support the allocation of health resources for the treatment of acute and chronic diseases across the lifespan,” according to the call for proposals.

Back at the Whitehouse, President Obama has been paying lip service to the clinical benefits of CER.  At the same time, he recently lamented that “the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill … there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place.”  That, he explained, was part of the need for “some independent group that can give you guidance” on the ethical dilemmas involved with rationing end-of-life care.

During her Senate confirmation process, Secretary of HHS Kathleen Sebelius declined to voice her support for prohibiting the use of comparative effectiveness data to withhold care from patients. Her ideas echo those of Tom Daschle, the tax-dodging health policy wonk who wrote in his book that the U.S. “won’t be able to make a significant dent in health-care spending without getting into the nitty-gritty of which treatments are the most clinically valuable and cost effective.”

Then there’s Peter Orszag, Obama’s director of the Office of Management and Budget and a major player in crafting health care reform.  For the most part, Orszag’s commentary on CER has been limited to lauding its ability to improve patient care while reducing waste.  But when asked a few months ago if the Obama administration has a position on empowering the CER board to make reimbursement decisions, Orszag said, “Not at this point.”

But perhaps of greatest concern is a January House report that included the following statement on CER funding:

By knowing what works best and presenting this information more broadly to patients and healthcare professionals, those items, procedures, and interventions that are most effective to prevent, control, and treat health conditions will be utilized, while those that are found to be less effective and in some cases, more expensive, will no longer be prescribed.

Sound familiar?  Cough, NICE, cough, ahem.

And as Jim DeMint explains, “CER is only one step in the Obama administration’s insidious plan to take over American health care … for our own good.”

But would CER really lead to health care rationing in the United States?  Of course.  That’s pretty much the point.  The debate is not about whether or not CER would be used for rationing, but rather, whether rationing is ethical and useful, and how far we’re willing to go to save a buck and level the economic playing field.

If health care reform shapes up as many Democrats anticipate, CER Institute guidelines will initially apply to the public insurance option expected to be the centerpiece of the Democrats’ proposal. But eventually they would slide down the slippery slope into the private sector. A public insurance option would also ride roughshod over the already anemic competition among overregulated private sector insurers, making the survival of private insurance unlikely.  As in the United Kingdom, recommendations will become rules and suggestions will become mandates in order to contain the costs of universal coverage.

To what extent will this result in government control of the doctor-patient relationship?  Ultimately, a bureaucratic board will determine when, how, and whether or not you and your family receive care.

Comparative effectiveness research will no longer be just a political hot potato; it will be the basis for the next great American culture war.  Instead of clashing over God, guns, and gays, we’ll battle over the monetary value of human life, the sanctity of doctor-patient relationships, the right to medical self-determination, and my favorite hot button issue, the duty to die.

Would cases like Terry Schiavo’s be decided based on financial considerations?

Where will fetuses fall on the QALY scale?  How about the elderly or people with Down syndrome?  Will they automatically receive limited treatment due to limited resources?

Will smokers be eligible for chemotherapy?  Will overweight people have restrictions placed on cardiac care?  Will we feel differently about those decisions when we’re footing the bill for everyone?

And you thought the abortion debate was contentious.

Obviously these questions address the most extreme examples of what could happen if we continue on our current path toward universal health care.  But government efforts at cost containment through CER may push us toward debating these issues sooner than we think.  Hopefully we’ll never see the day when questions like these go beyond an academic exercise.

Meanwhile, I’ll be saving up for a date with a mammography machine in one of those thriving medical tourism meccas.  I hear Costa Rica is a breathtaking location for a 35th birthday celebration.

May 26, 2009 · Filed Under Barack Obama, Health care

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Choice For Me, But Not For Thee

Health care provider conscience laws began to appear on the federal books shortly after the United States Supreme Court decided Roe v Wade in 1973.  These statutory provisions protect health care professionals from discrimination if they refuse to participate in abortion and sterilization services on the basis of religious or moral objections.

In 2008, the Bush administration issued a rule strengthening the requirements for compliance with the conscience protections set forth in the Public Health Service Act, the Church Amendments, and the Weldon Amendment.  Widely criticized as a nose-thumbing anti-abortion swan song for President Bush, the eleventh hour ruling was actually in the works for most of 2008.

Mike Leavitt, Secretary of Health and Human Services at the time, pushed for the regulation in response to a move by the American College of Obstetricians and Gynecologists (ACOG) and the American Board of Obstetrics and Gynecology (ABOG) to require pro-life physicians to provide abortion referrals as a condition of board certification.  Concerned that the ACOG and ABOG policies violated freedom of conscience and non-discrimination laws, HHS issued the final interpretive rule in December 2008.

The new administration moved swiftly to begin the rescission process when President Obama took office.  But, as Tabitha Hale points out, while the interpretation of conscience laws may change significantly under the Obama administration, it is highly unlikely that pro-life doctors will be forced to perform abortions any time soon.

And that just doesn’t sit well with Jacob Appel.  He’s a storytelling bioethicist with a fever, and the only cure is more abortionists.

You may remember Jacob Appel from his recent call for an abortion pride movement.  His latest lament is that the number of abortion providers has steadily decreased, and yet pro-life medical practitioners are still permitted to take up valuable slots in OB/GYN training programs.  He proposes that medical programs help abortion providers increase their ranks by using a pro-choice litmus test to screen OB/GYN residency applicants.

Using religious and moral objections to abortion to bar qualified doctors from receiving training in obstetrics and gynecology is a clear violation of conscience protection laws, but Appel has an answer for that.

In the case of abortion, the current shortage of providers justifies a limited waiver of conscience exemptions as applied to the training of new OBGYNs.  If we do not act, women may find themselves in a position similar to that of the criminal defendant who in theory has the legal right to counsel, but cannot find any lawyer willing to take her case.

Appel does not bother to address why a doctor who intends to specialize in geriatric gynecology, for example, would need to perform abortions.   He also neglects to consider that pro-life doctors are not the only ones who refuse to terminate pregnancies. Indeed, there are many pro-choice physicians who are just as unwilling to provide abortion services.

But the greatest flaw in Appel’s argument is his contention that he is a champion of patient choice and access.  Appel is only interested in ensuring choice and access for women seeking abortion doctors, not for women seeking doctors who respect their beliefs because they share them.

A woman should be able to choose a doctor whose moral compass points in the same direction as hers. Families should know that their doctor shares their values and will remain faithful to them, especially in a life or death situation.  Revoking conscience protections would revoke patient choice, a violation that would offend more pro-choice liberals if they were, at the very least, concerned with being consistent.

Most liberal feminists would balk at receiving gynecological care from a dedicated pro-lifer.  Shouldn’t pro-life women be able to choose a doctor who doesn’t engage in professional practices they find morally objectionable?

Appel’s essay is not a harmless, isolated intellectual exercise.  His views are shared by many of the liberal feminist chatterati, including some in the medical community.

Dr. Julie Cantor, for instance, feels conscientious objection in medicine has gone awry, and that we, as a society, are far too tolerant of individual conscience.  Like Appel, she believes that “physicians and other health care providers have an obligation to choose specialties that are not moral minefields for them. Qualms about abortion, sterilization, and birth control? Do not practice women’s health.”  She feigns passionate support for putting patients’ interests first, but not so shockingly, that support does not extend to choosing a doctor one doesn’t consider an agent of death.

A doctor’s conscientious refusal to perform an abortion does not strip a patient of her constitutionally protected right to seek an abortion, not even if she has to get an advance on her paycheck and shimmy across the frozen tundra on her pregnant belly to reach the closest abortion provider.  The government is not your mom, your BFF, and your knight in shining armor all rolled into one convenient, omnipresent package.

There is, without a doubt, a demand for abortion providers in America.  There is also a demand for doctors whose work is informed by a pro-life perspective on abortion, contraception, sterilization, and end-of-life decisions.  It is not the government’s role to decide that one of these categories of professionals should be phased out because it is less valuable than the other.

When did it become acceptable to ask the government to facilitate the subordination of a pro-life patient’s dignity to a pro-choice patient’s dignity?

April 7, 2009 · Filed Under Abortion, Health care, Liberal Absurdity, Women

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ObamaCare: More of the Same Sicko Ideas

When Barack Obama convened a White House forum on health care reform last week, there was one ground rule: check fresh ideas at the door. Of course, you’d never know that from Obama’s opening remarks rife with the usual bipartisan Mad Libbery:

In this effort, every voice has to be heard. Every idea must be considered. Every option must be on the table. There should be no sacred cows. Each of us must accept that none of us will get everything that we want, and that no proposal for reform will be perfect. If that’s the measure, we will never get anything done. But when it comes to addressing our health care challenge, we can no longer let the perfect be the enemy of the essential. And I don’t think anybody would argue that we are on a sustainable path when it comes to health care.

Despite the inclusive rhetoric, invitees were carefully selected to ensure no contraband proposals made it past security checkpoints.  Among the attendees were the usual suspects:

The vast majority of the groups represented at the summit strongly support a federal health insurance plan, and some are even advocates of a single-payer system. The list of summit participants included no fewer than nine unions: SEIU, UFCW, USW, Teamsters, UAW, CWA, Change to Win, AFSCME, and AFL-CIO.

The attendance list also included Physicians for a National Health Program (“Our Mission: Single-Payer National Health Insurance“) and other liberal advocacy groups such as the Center for American Progress, Campaign for America’s Future, AARP, Planned Parenthood, Families USA, and Health Care for America Now.

Advocates of free market health care models were conspicuously absent.  Michael Cannon notes that the guest list excluded representatives from some of the top health policy think tanks in the world, including:

  • American Enterprise Institute (the #5 think tank in the world for health policy)
  • Cato Institute (ranked #7)
  • National Center for Policy Analysis (ranked #10)
  • Manhattan Institute
  • Pacific Research Institute
  • Galen Institute
  • The Heritage Foundation

What could analysts from these policy centers bring to the table?  Here’s just one example of an innovative approach to health care outlined by John Cochrane in a paper published by the Cato Institute.  He proposes a systemic reform that would separate health coverage into two products: medical insurance and what he calls health-status insurance.  “Medical insurance covers your medical expenses in the current year, minus deductibles and copayments. Health-status insurance covers the risk that your medical premiums will rise,” he explains.

John Cochrane’s free market solution would provide portability, preserve choice, and increase affordability. But as Reason Magazine’s Ronald Bailey points out in his excellent summary of the plan, Dr. Cochrane did not receive an invitation to the White House summit.

John Cochrane and other creative thinkers have been locked out of the debate, but the Teamsters and UAW have the president’s ear as he prepares to make a $634 billion down payment on health care reform. What happened to “every voice has to be heard”?

March 13, 2009 · Filed Under Barack Obama, Health care

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Time to Get Some

Nearly half of the 45 million uninsured Americans could join the ranks of the insured tomorrow. No need to wait for McCain or Obama to implement a plan after taking office in January – their insurance coverage could begin now. How, you ask?

They could go get some. Watch Nick Gillespie’s simple proposal:

Most of the millions of uninsured Americans go without health insurance only because they don’t feel it’s a budgetary priority. And most of those people aren’t one-legged single Katrina victims with 12 kids (or whatever sob story Obama likes to cite at his rallies.) They’re young, healthy people who choose to take calculated risks.

The figures cited in this video don’t lessen the import of American health care reform, but they do offer some worthwhile perspective on the uninsured.

October 10, 2008 · Filed Under Health care

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