So Much For Comparative Effectiveness

The Obama administration’s commitment to cost control in health care can now be summed up in four words: Not on our watch.

Health and Human Services Secretary Kathleen Sebelius told American women this week that they have nothing to learn from the science that led to the U.S. Preventive Services Task Force guidelines on mammography.Insurance companies won’t change their payment policies, and the independent doctors and scientists who made up the USPSTF task force “do not set federal policy” or determine what services are covered by the federal government.”

What a golden opportunity has been missed to educate Americans about the implications of their health care choices. Otis W. Brawley, the chief medical officer of the American Cancer Society, in an op-ed in today’s Washington Post condemning the USPSTF guidelines, confirms that mass screening would only save at a maximum 600 out of the 4,000 women under 50 who die of breast cancer annually. What he failed to point out is that 1.14 million American women would have to be screened annually for ten years to achieve that goal. To cover the entire cohort (all women between 40 and 49) to replicate that benefit every year would require screening 11.4 million women annually. The cost, at $200 per mammogram (my initial estimate was accurate, according to this New York Times business section article), would come to $2.24 billion annually for the health care system.

I repeat my argument from Tuesday. Let’s start on day one and ask this question: The health care system (you can’t say the government in our mixed public and private payer system) has just come up with an extra $2.24 billion to spend on reducing breast cancer mortality in the U.S. population. Not only that, we get to spend it year after year. Should we spend it on mammography for women under 50? Or should we target that money for free mammograms for women of all ages who smoke, who are obese and who have a family history of breast cancer? Should we target that money to free mammograms for women of color, who have a much higher risk of breast cancer (perhaps because they are more likely to smoke or be obese)?

And as far as the coverage is concerned, I have yet to see a single story that quantified the harms of mass screening. How many false positives and unnecessary biopsies are there for every breast cancer caught early? How many actual, treated positives turn out to be very early stage ductal carcinoma in situ, minor breast duct growths that may dissolve on their own? A recent AHRQ analysis suggested that was about 20 percent of all growths identified during mammograms. According to Greg Pawelski’s most recent comment on GoozNews:

Research by the Nordic Cochrane Centre in Denmark raised questions about the effectiveness of mammography. In a study of 2000 women, they found that one woman would have her life prolonged but 10 would undergo unnecessary treatment and 200 women would experience unnecessary anxiety because of false positive results.

Health care is complex. Most treatments that “work” only work in a fraction of the people who get that treatment. Each has risks, which also affect a subset of those treated. Evaluating value is a trade-off between risks and benefits. Because breast cancer is such a high profile issue, the new mammography guidelines offered the Obama administration a chance to educate the public about the trade-offs involved in making those choices, and how the nation might wring more value out of the money it spends on health care.

Alas, the administration punted. In the midst of a political battle over health care reform, where nihilist Republicans are braying about profligate spending on the one hand and letting nothing stand between you and your doctor on the other, the politicians in charge of health care policymaking saw that offer as one they had to refuse.

Correction: An earlier version of this post mistakenly said there were 4,000 deaths from breast cancer per year among women under 40. I meant women under 50. And Greg Pawelski is not a physian or a Ph.D.

Merrill Goozner has been writing about economics and health care for many years. The former chief economics
correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect, The Washington Post and The Fiscal Times. You can read more pieces by Merrill at  GoozNews, where this post first appeared.

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  1. Just like Ms. Gur-Arie states about graduating more doctors–as a new-nurse and sick and tired of hearing about the nursing shortage in the U.S…why aren’t there monies invested in more nursing programs? And if the so-called Magnet hospitals only want an RN with a BSN degree and moan and complain that they have a shortage–why don’t the hospitals work out an incentive program with the associate’s nurses to obtain a BSN? I am so confused and angry when I hear that the U.S. is going on a crazed nursing recruitment from the Phillipines and other countries to “fill the nursing shortage gap”. There are so many nurse graduates –recent graduates who cannot find employment. Even President Obama recognizes this. First employ the U.S. citizens then look past our borders for help. My co-grads and i included are ready willing & able to work hard in hospitals.

  2. When will Dartmouth report on the cost of medical errors/poor quality? Of those they studied, how many were in their last 2 years of life because of their medical treatment?

  3. And why do we limit the ratio of teachers to nurses in nursing school, but no limit on nurse-to-patients? Bev MD, I read the beginning of your long post, I’m not asking why it’s taking so long, I already know why. Lack of leadership. Dr. Berwick has said pretty much the same thing, why are we pouring so much money into hc and not looking at the value we’re getting for our dollar? You’re just not angry enough, Bev MD. Margalit is correct if information were made public, that would be a good start. Patients don’t have a choice and don’t have enough information to make a good choice. Bev MD #1 you are correct, which is why we recommend every patient have an advocate 24/7. Why are advocates kicked out? Labeled as “visitors?” Kept away from physicians? #2 Correct again, so why do we continue to leave this dysfunctional industry to govern thyselves? They’ve done an abysmal job. We accept the status quo? “It’s complicated, some are trying” isn’t good enough for me and shouldn’t be good enough for anybody. 3 4 and 5 correct correct correct. 6. I strongly disagree with you on this one. I agree with your last paragraph, no matter who is paying. My husband was hospitalized for 108 days, it didn’t cost us a dime. I regularly had a laundry list for the insurance case manager of items they should NOT pay for, call it a conscience but I knew this was costing somebody a fortune and his “treatment” (I just can’t call it care) was egregious. Fat lot of good it did, insurance companies just keep passing costs along.

  4. Bev, patients don’t actually have to pay in order to influence quality. Besides, hospital care is frequently in the catastrophic bracket for most people.
    However, if the data was collected and made public (feds can do that), it is likely people would chose hospitals with better records, and if you want to encourage that behavior, reduce the copay for the “good” hospitals. I think Barry was suggesting tiered copays as a way to reduce costs.

  5. Lisa;
    There are many others smarter than me who can explain why the system has not changed faster; Don Berwick being one (see his book “Escape Fire.”) The causes, like errors in all organized systems, are multifactorial. However, here’s how I see it as a retired hospital-based physician. I confine my remarks to inpatient care as that is my area of experience, but what goes on in physicians’ offices (which I have experienced as a patient) is another novel in its own right.
    1. The process of taking care of a sick inpatient is recognized as more complex than almost any other industrial delivery system existent (see “The Innovator’s Prescription” by Clay Christensen). Complexity breeds a high number of steps in each process and high number of different people involved, which multiplies opportunity for error.
    2. There is NO country-wide unified organized system for improving processes which would reduce # steps and therefore opportunities for error. Make analogies to Toyota’s auto assembly production system or the aviation system for reference. Each hospital is trying, to a greater or lesser degree, but they are all trying their own thing, with much repetition, waste, and failure.
    3. There is NO incentive for fixing #2 right now. Reasons:
    a. costs lots of $$ and effort. Since improvement is difficult to measure (like measuring improvement in elementary/secondary education), CEO’s do not see any ROI.
    b. CEO’s see their primary mission as ensuring the survival of their hospital(s) in a hostile world. Since ROI in (a) is not visible, they regard it as inimical.
    Their primary focus is financial.
    c. Physicians, although they practice in hospitals (like MD as Hell), do not regard themselves as aligned with the hospital and often see it as the enemy of themselves and their patients. Therefore THEY also have no incentive to improve #2. Since they affect a lot of what goes on in hospitals, such as having the worst record in handwashing, they are part of the problem yet see others as the problem. CEO’s can’t control physicians’ behavior, and the physicians’ peers won’t control it, thus exacerbating #2.
    d. Insurance companies only care about minimizing their own risk since they make money by maximizing premiums and minimizing payouts, just as in any other insurance industry. They have no incentive to improve #2 either – just to pick healthy people to cover.
    3. The feds, although they have the potential power for forcing quality improvement, have no comprehension of the true nature of the problem and therefore no idea how to use their “gold” (Medicare, or whatever form of $$ they pay out to the industry) to fix it.
    4. The medical education system, at both the medical student and residency level, completely ignores systems thinking or formal quality improvement training which would enlighten docs as to how to improve processes and
    advocate for improvement to reduce errors.
    5. Ditto #4 for hospital CEO’s – if they are trained at all.
    6. The current legal system is a blunt instrument which only engenders fear and avoidance behavior without the mechanism to force true quality improvement. It also further pits the docs against the hospitals by trying to find ONE cause for an error, therefore encouraging mutual finger-pointing instead of collaboration for improvement.
    I’m sure I’ve forgotten many things, but I see nothing changing until there is universal incentive to change, and I can only see that universal incentive happening, by changing the payment system until only high quality is rewarded and low quality is drastically penalized. This can only happen when physicians, hospitals and insurance companies are forced to cooperate to achieve quality, rather than each pointing at each other. Unless patients start paying for their own care and are able to influence this, the feds are the only answer as, once again, they have the gold.

  6. Bev, how would you work with a system to change it? How would you personally go about doing that when that system tells you to go away? I spurn a government working against me. MD as Hell you are correct, especially teaching hospitals and we’ve been offering that advice for years, stay away from teaching hospitals. Bev, is a decade your definition of “yesterday.” How long are you willing to wait? Lucian Leape asks the same question, you willing to wait 100 years? You’re wrong, there is leadership for change (ie: Don Berwick) but there’s just not enough like him. No customer of any other industry would tolerate lip service and excuses that bad quality is the customer and society’s fault. Why are our standards so low when it comes to health care?

  7. Lisa;
    I am not familiar with you or your posts, but you can choose to be angry and want everything to change yesterday, or you can choose to work with the system and help change it, as Sorrel King has. There are so many problems with health care delivery today, one could spend weeks sitting in a room writing them all down. I do not accept your view that everyone in health care has your worst interests in mind; but a chaotically inefficient delivery system makes errors inevitable. A punitive legal system encourages if not demands silence (I have been there, done that with hospital lawyers.) There is no leadership for change unless mandated by the very federal government you spurn, because the one with the gold makes the rules. Sorry to be a realist.

  8. Lisa,
    I get the patient out of the healthcare system as fast as possible. That is the only safe play. Hospitals are very dangerous places and getting worse every year.

  9. Bev MD thanks for trying to be helpful but you are not telling me anything I don’t already know. I’ve been a pt safety advocate for the past 6 years, I know who and what everybody and everything is in this movement. I am correct about medical errors. Progress has been painfully slow, way too slow, and medical errors are a significant cost driver. As I have said in other posts, I have a real problem being mandated to finance this industry. You should, as well. We should all be outraged by the amount of money pouring into this industry and should start shining a very bright light on where that money is going and how it is being spent B E F O R E we dig into everybody’s pockets to keep it going. It is pathetic that Sorrel King has had to invest such a chunk of her life to improving the quality of HC after her daughter’s senseless and preventable hospital death. Believe it or not she’s one of the lucky one’s, Johns Hopkins embraced her and worked with her to try and prevent another senseless death. THE MAJORITY of those in the hc industry turn a blind eye and wait us out, just hoping we’ll shut up and go away, often they tell us to shut up and go away. You think Josie is the only preventable death? You think the Quaid babies are the only accidental overdose? See this: http://www.deadbymistake and this http://www.empoweredpatientcoalition.org, the only thing that makes Sorrel unique is she was involved with a hospital who has ethics and honorable intentions. Most DO NOT.

  10. LisaLindell:
    You are no longer correct about medical errors. Although it is (too) slow, attitudes concerning these errors are changing. There is movement toward and even some federal and state mandates regarding full disclosure and quality improvement. I just read “Josie’s Story”, by Sorrel King, concerning her daughter’s death by medical error, and the foundation for patient safety which she set up with the settlement money from Johns Hopkins. (www.josieking.org, I believe, is the website). I recommend you read this book. I am retired now but am fairly well read on the patient safety movement and can vouch for the people and events cited in her book, such as Dr. Peter Pronovost, Dr. Don Berwick, and others. In addition, the appendix to the book gives useful information regarding progress and resources in this arena.
    Another useful resource is Beth Israel-Deaconess CEO Paul Levy’s blog, “Running a hospital”, which contains several posts regarding quality improvement and patient safety. (Check the archives; I am not sure how to pick out those specific posts).
    As I said, it is happening too slowly, but it IS happening.

  11. What would it take for clinicians and patients to know with a reasonable degree of certainty whether a particular test, procedure, medication or other action–for a particular patient with a particular condition (or conditions/co-morbidity)–is worth the money (i.e., is cost-effective)? Yes, we already have such knowledge in some situations, but ignorance often (usually?) prevails.
    We ought to engage in earnest in an evolutionary, interdisciplinary, worldwide collaborative process of knowledge building, guideline dissemination, and ongoing assessment & revisions that is guided by sound science. And we ought to continue as long a humanity exists. The current day controversy, imo, simply points to that need!

  12. MD as HELL,
    I was asking a question because I haven’t dug into the details myself, but have heard that reform was enacted and that it reduced med mal lawsuits, but that practice patterns hadn’t changed.
    Peter and LisaLindell raise I think the most relevant point related to costs: if the lawyers have a low-enough cap on their fees, they aren’t going to take many/any lawsuits where they are paid based on the award.
    Here is a link on the effect of the legislation that indicates the malpractice reform in Texas went way beyond caps on damages and had a major effect on lawsuits:

  13. C3 and bev, all good points and examples. I’m not a clinician (I’m one of those evil insurance types- hopefully I’m an Enlightened Insurer) so defer to your experience.
    Your examples raise an interesting thought about the effect that lag of information and practice changes have on healthcare. At a single point in time, a medical service’s value/benefit can be 1. unknown, but believed to be beneficial, 2. confirmed to have known value/benefit and in current use, 3. of dubious value or harmful, and no longer used, or unfortunately 4. of dubious value or harmful and still used. There was a gov’t study (I can’t find it) that estimated that it takes 17 years from the time of a medical discovery to be incorporated to the bedside. I believe it meant it takes 17 years for outdated practices to disappear from the healthcare system entirely too.
    It would be a good doctorate study to plot out the universe of medical services to see where they are on this lifecycle of evidence-based validation and utilization and use it to identify ways to speed up this cycle, therefore reducing the time a harmful or useless product/service. I am afraid there are too many serivces out there that are stuck in the the “unproven but believed to be of value” and “disproven but still in use” categories for many many years.

  14. The caps on damages in Texas are effective at keeping victims out of court. Good luck finding a lawyer in Texas to take a med mal case. Your suggesstion of “health courts” presided over by judges with a medical background smacks of the cronyism that already exists in every regulatory agency involved in the health care industry. From medical boards to the Joint Omission, nobody is protecting the patient from harm. N O B O D Y.
    Defensive medicine? Unreasonable patients? And still nobody is discussing the cost of medical errors. Let’s all just ignore that problem and pretend it doesn’t exist.

  15. Bev MD and MD as HELL,
    I would be interested in your gut feel level estimate of the percentage of U.S. healthcare costs that are driven by a combination of defensive medicine and trying to placate often unreasonable and inappropriate patient expectations. The liberals would have us believe that it is a very low single digit percentage. My own guess: 10% at a minimum. Throw in Medicare and Medicaid fraud and futile end of life care and we’re talking real money before we even deal with comparative effectiveness and cost-effectiveness research in trying to determine coverage and payment policy.

  16. Yeah Peter, I take the Post and read that article when it came out. Once again, I am not disputing you that some docs are just out to make $$. This is a different issue than defensive medicine practices, however. If you didn’t allow docs to own their own CT scanners or anything else, you would still have a problem with defensive medicine, so stick to the issue.

  17. Next time you come to your doctor with a seemingly simple complaint and he/she offers a test to rule out a certain diagnosis tell them no thank you because there is no possibility that you are the needle in the haystack. The only way this will work is when american society is ok with a certain rate of missed diagnosis for these conditions and say if it does happen its bad luck it happened to you, end of story. Life aint fair, cant have it all folks

  18. In support of c3; medical history is littered with such examples. In the 30’s and 40’s for example, the “ideal” contrast medium for x-rays, Thorotrast, was found. Unfortunately it was discovered that it gave patients cancer up to 30 years after its administration…….100x risk for liver cancer, 20x for leukemia, etc.
    Just because we are theoretically more advanced now does NOT mean the next Thorotrast is not already upon us.
    (I did not find the anonymous statement that c3 quotes, so this may be out of context.)

  19. Annonymous;
    I struggle to come up with one example of a test/procedure that has been proven (with unanimous support) to be of no benefit or harmful in every case
    That’s a pretty tough challenge since “proven” and “unanimous” are moving targets (i.e. as evidence comes in, opinions change). However, I would suggest you read about the history of x-ray pelvimetry in difficult labor. There’s a test that at one point in time was widely accepted as a way to prevent significant neonatal and maternal harm. In the long run it was a useless test (no better than a coin flip) and it lead to maternal harm (i.e. unnecessary c-sections) and neonatal harm (i.e. unnecessary radiation exposure)

  20. Uh, hang on Peter; we’re talking about CT scans and stuff that have no effect on the doctor’s income. I hear you about marginal surgeries and such, but most defensive medicine has to do with laboratory and imaging tests that do not make any more $$ for the doc – and that’s what the last few comments have been addressing. Don’t go overboard!

  21. Barry:
    “With tort reform, I think doctors also need to be prepared to accept more accountability…”
    ” I don’t want to be appearing in any court. Period.”
    And that’s the arrogance of doctors. When Texas instituted it’s tort “reform” it gave more power to the medical board, so guess what happened – doctors didn’t like that oversight as well.
    Does anyone think that if docs were given absolute immunity they would say; gee I can survive on less income, let’s stop doing all this unnessesary fee for service stuff that buys me the vacation homes and strip malls. Does anyone think that hospital budgets could take the hit from the all of a sudden ethical practice of medicine by their doctor staff.

  22. Barry Carol,
    You are missing the point. I don’t want to be appearing in any court. Period. I also will test any patient to my satisfaction regardless of the tort environment. I have to believe in what I do for each patient. Also part of what I do is decrease anxiety in patients (or parents).
    In the dark days when the CT scanner at my hospital was mobile and was only here half the time, there were fewer scans, despite the mantra “if you need it then the distance is no reason not to get it.”
    Parents now really demand a CT scan for their child with a head bonk. They would not be in the ED if they had any thought to the contrary. It is starting to be that way with abdomenal pain. The other day I told a mother her child was fine and needed nothing. She was very unhappy. The next day her pediatrician got some normal lab work on the child. The child was fine but the mother never will believe I did enough for her child. No one paid me for the negative impression I made. I would have been the hero getting unnecessary lab work and a CT, all of which would have been normal. This way I am the goat.
    If the patient had to pay for the test, they would not be clamoring for unnecessary care.
    Don’t empower 50 million more people to stampede the system with their brand new coverage and expect costs to go down.

  23. Bev M. D. – Regarding the patient who presents with a headache but there is only a 1 in 1,000 chance or less that it is anything serious, I wonder how physician behavior might change if (1) they had robust safe harbor protection from lawsuits if they follow evidence based guidelines, (2) disputes were handled by special health courts and not lay juries, and (3) insurance didn’t pay for MRI’s under these circumstances.
    If a doctor could tell a patient who wanted an MRI that (a) the situation doesn’t call for it, (b) insurance won’t pay for it and (c) there had already been a few cases where patients who turned out to be the 1 in 1,000 that had the brain tumor but didn’t get the MRI sued but health court judges ruled in favor of the defendant(s) on a Summary Judgment basis and (d) those rulings carried the power of legal precedent. If a doctor can’t refuse to order an MRI under those circumstances unless the patient is prepared to self-pay, I would throw up my hands regarding the ability of tort reform to reduce defensive medicine related healthcare costs.
    With tort reform, I think doctors also need to be prepared to accept more accountability including being grouped into tiers based on cost-effectiveness and quality with patients being responsible for higher co-pays if they choose doctors and hospitals outside the preferred tier.

  24. I would hate to say I agree with MD as Hell (OK, just poking fun), but he is actually correct about Texas. People don’t understand that it is not losing the lawsuit that drives defensive medicine, it is the fear of being sued in the first place, and the undeniable fact that the legal system is a lottery. It is this fear that drives the “unnecessary” testing, plus the fact that medicine is inherently a needle in a haystack phenomenon. That is, in a large haystack of people with headaches, there will be one needle where the HA is caused by something serious like an aneurysm or a brain tumor. When a patient comes in with a HA and literally demands a CT scan, how does the Dr. know if he is the needle or the haystack? And what will inevitably ensue if he is the needle but the CT scan is not done?
    That is why tort reform does not reduce costs.

  25. Margalit – Believe it or not, we’re not far apart. I’ve always liked vouchers conceptually, and if I were starting with a clean sheet of paper, that’s what I would do. As I’ve said before, financing needs to be transparent so people understand exactly how much they are paying for health insurance. I like Dr. Emanuel’s idea of a dedicated VAT, but I don’t think his proposal of a 10% tax rate will raise anywhere near the amount of money he suggests it will after inevitable exemptions for food and other necessities are factored in. We would probably also need a flat tax of 5%-6% or so that I would apply to all income including investment income above the federal poverty level but would cut it off at $250-$300K of income or so. I would ensure that the top marginal ordinary income tax rate above $300K was at least 40%. It is scheduled to return to the 39.6% rate that prevailed under Clinton once the Bush tax cuts expire at the end of 2010.
    There are two areas we differ, I think. One is the scope of coverage. I would want to know more about what’s covered and what isn’t in what you call the basic FEHBP. I’m more inclined toward a catastrophic insurance only approach with, say, a $5K deductible for an individual and $10K for a family, though I’m well aware of the arguments regarding the inability of lower income people to afford the deductible. I think it’s more important to keep the overall cost that needs to be covered with tax revenue as low as possible. Also, rather than one size fits all, I would allow people with sufficient income or assets, to be defined, to opt for a higher deductible than the coverage mandate calls for and, in effect, receive change for their voucher if they buy a lower cost policy. People can buy additional coverage if they want to and can afford to.
    I note that we almost had national health insurance in 1974 before organized labor prevailed upon Senator Kennedy to kill the bill. Democrats wanted basically what you are proposing in terms of coverage but with a $1K deductible and Republicans wanted a $1,500 deductible. Multiply by a bit over 5 times to translate those numbers to today’s dollars. Since President Nixon was weakened by the Watergate scandal, however, organized labor anticipated a landslide election win in the 1974 elections and thought it would be able to ram a single payer system through over Nixon’s veto. Instead, Nixon resigned in August, 1974, a severe recession set in, and suddenly there was no longer any money for new entitlement programs. In short, Democrats and organized labor overreached and wound up with nothing. Kennedy later regretted not making that deal with Nixon when he had the chance. The message from this saga: don’t overreach.

  26. Barry,
    Public education is not failing because it’s public. There are excellent public schools out there. There are other reasons for inner city failure and those indeed need to be addressed. I am not sure that vouchers to Catholic schools are the answer and I wouldn’t want to see for profit schools.
    Since you mentioned vouchers for schools, why not use the same mechanism for health care? Have the government collect taxes, set a minimum acceptable coverage (I’m sticking with basic FEHBP) and provide everybody vouchers to pick the private insurer of their choice. Private insurers will be mandated to accept all comers and provide the minimal coverage in return for the voucher. Anything above the minimum costs money. The government will regulate this one plan only and insurers will be barred from offering anything less, but free to offer more.
    Would that pass the free enterprise litmus test? This way all employees are going to know exactly how much health care costs and maybe act to reduce the tax burden.
    This would be in addition to all cost cutting measures that everybody is bringing up, and I would include negotiating brand name drug costs on behalf of all insurers.

  27. jd
    Please tell me you are smarter than this. Texas does not have tort reform. They have caps on awards. Well BFD!! The doc still got sued to get to that point. That is the problem!! Every doc that did not get sued tried to be bullet proof (Lawyer proof). Tests keep docs out of court. Court is not about the truth. It is about shading the truth your way. A normal CT scan or cardiac cath kills a lot of law suits, but they cost a whole bunch. Let me be the doc making reasonable choices and I’ll spend a lot less. Leave me out on the freeway and I’ll spend whatever it takes not to get hit.

  28. OK, Obama and congress control my healthcare costs. Just don’t take control of my health, I care. There needs to be a balance of cost cotainment and freedom of choice.

  29. “…everybody has a right to a decent education and a fair chance to succeed…”
    Margalit – Of course, they do. The problem here is what do you do when the public education monopoly chronically fails the kids, especially in our inner cities? Suppose Catholic schools, for example, are achieving better results educating low income students at half the cost or less that public schools are spending? If they have extra capacity to take in more of these kids, why can’t we use tax dollars for vouchers to give these students a viable alternative to the failing schools that they’re currently trapped in? The teachers unions staunchly oppose this and their Democratic allies in the Congress back them up. The same is largely true at the state level.
    Our Federal Trade Commission expends a lot of effort to ensure that private markets are reasonably competitive. Proposed mergers between companies in the same business have to pass muster with the FTC to proceed. It’s too bad that we don’t apply the same standard to public K-12 education. There is plenty of competition between public and private colleges. Low income students can spend their Pell grants at any school they can get into. Why isn’t the same standard applied to elementary and secondary education? I don’t know about you but I frankly resent having to pay ever higher taxes each year to the State of NJ to support and sustain failure in our inner city schools with no viable alternatives available because of opposition from teachers unions.
    As for economic progress or lack of it among the middle class, employer provided health insurance benefits, along with pensions, 401-K plans and other benefits are part of total compensation. The rapid rise in healthcare costs leaves less money available for wage increases. Total compensation (wages plus benefits) grew far faster than wages alone over the last few decades. A considerably higher percentage of compensation is now accounted for by health insurance benefits. Most employees don’t have a clue about how much their employer is spending on their behalf to provide these benefits. If they knew, they might show more interest in shining a light on doctors, hospitals, drug companies, device manufacturers, labs and other providers and ask hard questions about why the cost of these services, tests and procedures are increasing so much faster than everything else we buy.

  30. I’m not sure about the right percentage of taxes. I guess it depends on what you get for all the taxes you pay. It is tempting to say that we should keep more of our earnings and have the freedom to decide how to spend it.
    That may be true for most goods and services, but it cannot be true for things like education for example. A certain optimal level needs to be provided even to those that obviously cannot pay for it.
    Why? If you are a liberal, you would say that it is a social service and everybody has a right to a decent education and a fair chance to succeed and so forth and so forth.
    But education for all is also something that serves the rich very well. Without an educated workforce, it wouldn’t be so easy to amass fortunes, so you don’t hear much about socialized education.
    How about health care? It is less obvious that universal health care is a necessity for business to thrive. Even on this blog, people often suggest that the poor, which really includes middle class nowadays, should forgo buying fancy goods and pay for their health care first. So instead of buying big screen TVs, or cell phones or a new car, people should prioritize responsibly and buy health care insurance.
    Does this sound like a boost to the economy? I don’t think so.
    This is why the rich and the large corporations should pitch in and bear a disproportionate part of health care costs. An impoverished population is not good for business. Short term greed is bound to come back to roost in the long term future.
    I don’t think that the shrinking middle class can finance much anymore. I wish it could, but for the last few decades the minuscule upper class has been consistently improving its lot at the expense of everybody else and the well is just about dry.

  31. Just to follow up on the potential of very high marginal income tax rates and high tax burdens generally to inhibit the economy’s ability to grow and create jobs, I’m reminded of a criticism the late Democratic presidential candidate Paul Tsongas of Massachusetts leveled at his fellow Democrats. He said: “Democrats love employees; it’s employers they can’t stand.” Trying to soak the so-called rich ad infinitum to pay for healthcare and health insurance reform or anything else for that matter, is a dangerous strategy, especially with unemployment and underemployment where it is today. Over the long term, if we as a society really want these programs, the broad middle class will have to pay much of the cost to finance the social programs for the broad middle class and the poor. There are simply not enough rich people to tax at high rates to finance the Democratic agenda while giving the middle class a free ride.

  32. Margalit,
    I would like to address your comments regarding taxes, health insurance benefits and compensation at insurers and hospitals.
    Taxes – To fund health insurance via a payroll tax would offer the virtue of transparency. However, we already have a 2.9% payroll tax with no wage cap to finance Medicare Part A benefits. The tax is split evenly between the employee and the employer though most economists will tell you that the employee really pays the employer’s share as well in the form of lower compensation than would have otherwise been paid. There is an additional 12.4% payroll tax on the first $106,800 of wages to finance Social Security and Disability benefits, also nominally split evenly between the employee and the employer. If we were to replace private health insurance premiums with a payroll tax, I estimate it would take a tax rate in the 15% range to get the job done and it might even have to be a bit more than that. These taxes, if only applied to wages, would exacerbate the tax gap between wage income and investment income from interest, dividends, capital gains and rent. Moreover, people who are in business for themselves or operate small businesses or otherwise don’t have their income reported to the IRS on a W-2 form will have enormous incentive to underreport or hide income to an even greater extent than they do now which is considerable. A Value Added Tax, if it were completely dedicated to healthcare as Dr. Emanuel advocates, would also be transparent and it would have the virtue of collecting taxes from people who are earning their income in the underground economy or otherwise underreporting what they earn. The poor can be protected by exempting necessities and offering rebates. The Earned Income Tax Credit (EITC) was originally passed to provide a way to rebate payroll taxes to the working poor in order to give them a greater incentive to work rather than rely on welfare.
    I think the attitude among many that high income people can always pay more no matter how much they are already paying is dangerous. There is a point where high marginal rates affect the willingness to invest, take risks and create jobs. From a macroeconomic standpoint, when the total tax burden (federal, state and local combined) gets too high, it can impede the economy’s ability to grow. The problem is that even economic experts don’t have a good handle on exactly where that point is. For what it’s worth, I think a reasonable total tax burden (again, federal, state and local) for an upper income person in America is in the 33%-35% of income range excluding corporate income and property taxes which are built in to the price of the goods and services I buy. I don’t think the top combined federal and state marginal income tax rate should exceed 50% even for Bill Gates or Warren Buffett. Anything above 50% makes the government the senior partner in the taxpayer’s life which I think is wrong on its face. Plenty of liberals don’t have any problem with it, however.
    FEHBP Plan – The health insurance plan for government employees is quite rich. While I don’t have exact figures, the actuarial value which is a measure of coverage at average medical prices for a standardized population, is more generous than many employer plans which are already quite expensive. Mandating even more generous coverage is likely to drive average premiums even higher thereby exacerbating the insurance affordability problem.
    Compensation – In most businesses, wages and benefits for the majority of jobs are set based on local market conditions. For insurers, these jobs would include computer programmers, call center people, clinicians, sales and marketing people, underwriters and the like. For senior executives, the competition is national and may include different but related industries. Companies don’t just throw extra compensation at people just to hide profits though bonus pools are more generous in good years than in bad years. Outside of Wall Street, since the vast majority of rank and file employees are not eligible for bonuses, the bonus pool is a small percentage of total corporate compensation and an even smaller percentage of the total wage plus non-wage cost base.

  33. First, the Cochrane Collaboration data (the largest study that backs what the Preventive Services TAsk Force is saying) is internationally recognized as the gold standard for this type of reserach.
    Secondly, back in the early 1990s, the National Cancer Institute tried to tell Congress that, for many women, the risks of mammograms might well outweigh the benefits. See story here http://www.healthbeatblog.com/2009/11/more-on-mammogramsand-conservative-opposition-to-comparative-effectiveness-research-.html
    Based on the research, the enormous number needed to treat to save one life, the very, very long odds of dying of breast cancer for any individual average-risk woman like myself, and the risk of false positives–(not to mention the risk of having a breast removed unnecessarily) I stopped going for mammograms years ago.
    So, I personally am persuaded by the evidence.
    But I don’t think that we have “lost” a huge opportunity to make use of comparative effectiveness research.
    Breast Cancer is an enormously charged issue. We, as a nation, have been hysterical on the subject for as long as I can remember.
    And for good reason. For the last thirty years, our doctors, our government, feminists geniunely concerned about womens’ health, the American Cancer Society etc., all have been telling women that we Must have mammograms every year, or we will die an ugly, painful death, leaving our children orphans, etc.
    Now, someone decided it’s time to tell the public the truth. At this point, you really can’t expect the public to turn on a dime and say “Oh, okay . . . I guess that wasn’t true after all.”
    See Naomi Freudliche’s extremely thoughtful piece on the problem on HealthBeat http://www.healthbeatblog.com/2009/11/new-mammography-guidelines-hit-the-wall-of-public-opinion.html#more
    (Her piece was also re-posted on Alternet.)
    This is why will have to continue covering mammograms and both the government and private insurers realize this.
    But I’m not happy with what Sebelius said. She seems to be suggesting that women should ignore medical evidence. Instead, she should have said: “Rest assured, we all continue to cover mammograms for all women who want them. At the same time, average risk women should talk to their doctors about the risks as well as the benefits of mammograms, and then decide what is best for them. This should be an individual decision
    I agree that, from a political point of view, the timing of this annouoncement was terrible. The Cochrane studies were completed a number of years ago. I can’t help but wonder: by announcing this now, was someone trying to undermine reform, handing conservatives just the material they needed to fear monger about how “gov’t health care” weill “ration” care?
    Finally, I would emphasize that mammograms are very different from MRIs, CT scans or a host of other tests and treatments. In many other cases, it will be much, much easier to educate the public, and people will accept that more care, or more agressive and expensive care is not necessarily better–just as we persuaded the public that brand-name drugs are no better than generics.
    We’ll use higher co-pays to steer patients away from less effective treatments, just as we used higher co-pays to steer patients away from those brand-name drugs–and used very low co-pays to steer them toward generics.
    Lower fees also will help steer physicians away from less effective treatments.
    The brouhaha over mammograms is hardly a definitive test case as to whether we can and will use comparative effectiveness research.
    But in this particular case reformers cannot –and should not– suddenly refuse to cover the test..
    Reform is going to have to be subtler and more sensitive than that, or it will implode.
    As I’ve said before, reform is a process, not an event.
    It will take time to educate patients, and doctors.
    You don’t educate people by pulling a rug out from under them.

  34. Barry,
    Non profit status in health care needs to be reexamined, particularly for hospitals.
    I’m not sure which insurers you are referring to where the net profit margin is 1% – 2%, but there are ways to “lower” your profit margins and one of them is to dole out all sorts of “compensations” and the other one, used by hospitals, is to throw money at infrastructure.
    I don’t know about tort reform. The evidence does not suggest any overall cost benefit, but having specialized courts and no caps seems logical.
    Ultimately though, there needs to be a real reduction in cost of services and while I don’t think that single payer is the only answer, single collector and single regulator must be. If the government collects premiums through progressive taxation (just another line item in your payroll tax) transparency is served very well and so is equity, as “socialist” as it may sound. VAT has a tendency to hit the poor harder.
    If the government regulates one plan and one set of services (basic FEHBP) and insurers are forced to offer it at the very minimum, with anything above available for an additional price, you can still have private markets and competition, albeit on different terms.
    Which brings us of course to that set of services and the rationing dilemma. Rationing is perceived as evil only when there is severe scarcity. A basic FEHBP plan, as defined today, would not be adversely received by most people, since most people, whether they know it or not, have less coverage already.
    As to “waste” in the form of mammograms for those younger or older than the guide lines, the waste is apparent in “routine” mammograms, not mammograms performed after careful consideration, no matter the age of the patient. Here is where education and responsible behavior of patients and mostly doctors comes in. I said it before and I will say it again, physicians must get on board and understand that they are the ones holding the keys.
    So instead of marginalizing practicing doctors and requiring that they adhere to rules created by committees, why don’t we appeal to their self respect and education and the heightened moral responsibility of this entire profession?
    I can hear the skepticism, but I strongly believe that by and large doctors will do the right thing. Many already do. Throwing in financial incentives to do the right thing will help too.
    If not, one of these days, we will really have to ration care severely.

  35. “Well then Peter, how about having health care come out of our taxes as well? Would it change the frame of mind?”
    Yes, because we would be voting to take it from ourselves. I am for healthcare paid for through taxes.
    “Most experts that have looked at this conclude that a switch to a single payer system might save between 2% and 5% of healthcare costs and that would be only a one time saving. It would do nothing to impact the medical cost growth curve.”
    What experts? Why are single-pay countries doing it for 50% of our expenditures? Barry, if you assume the ONLY change is a single-pay payer/administrator and nothing else changes in the system I would probably agree, but single-pay also assumes universal budgets, price/service cost regulation/negotiation, community owned hospitals where reducing untilization to achieve budget is actually rewarded and CEOs don’t make 7 figure incomes and there are no insurance companies in basic healthcare with their loyalty is to shareholders and multi-million dollar CEO bonuses/salaries first and not patient care and system financial sanity.
    “As I understand it, the main tort reform in Texas is a cap on non-economic damages.”
    Yea, it’s $250,000 on non-economic damages. There’s no money to pay the lawyers and when you can’t pay the lawyer no one wants your case. Tort reform is good for doctors, good for insurance companies, but has no effect on healthcare expenditures.
    “Other research indicates that although medical malpractice caps reduce the burden on insurers, they do not alleviate the growing problem of skyrocketing insurance premiums. One report reveals that limitations on medical malpractice awards produced payout averages 15.7% lower than those of states without caps between 1991 and 2002. This statistic is true despite the fact that many of the states did not institute the limitations until near the end of the reporting period. Meanwhile, the median annual premium in states with caps increased an alarming 48.2%. Surprisingly, the median annual premium in states without caps increased more slowly: by 35.9%. In other words, the median medical malpractice insurance premiums were actually higher in states with caps. This is contrary to the goal of the limitations on medical malpractice awards.”
    The AMA link ironically refers to McAllen Tx as a justification for tort reform – you remember that one Barry – http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

  36. jd,
    As I understand it, the main tort reform in Texas is a cap on non-economic damages. I don’t know to what extent they eliminate venue shopping and/or require a certificate of merit to proceed to trial. I’ve said numerous times that I don’t think damage caps are the answer to the tort problem. If I were a doctor, I would want to have confidence that if I were sued, the dispute would be handled objectively and fairly. To me, that means health courts presided over by judges with requisite medical expertise and the ability to hire neutral experts to help sort through the science. It does not mean putting the matter in the hands of a lay jury that could be easily swayed by a glib trial lawyer in a plaintiff friendly jurisdiction.
    Admittedly, medical culture is an important factor and difficult to change. In McAllen, TX, the culture is entrepreneurial and money driven. At the M.D. Anderson Cancer Center, it’s trying to cure cancer, pioneering new medical knowledge and generally doing whatever it takes to keep the patient alive as long as possible regardless of cost, especially if the patient is well insured.
    To supplement tort reform, I think we need robust price and quality transparency tools so that referring doctors are equipped to more easily identify the most cost-effective providers. Some doctors practice more defensive medicine than others while some are more money driven than others. Transparency tools could help to reward the most cost-effective providers with more patients and penalize the high cost providers. Tiered co-pays could also help to steer patients toward the most cost-effective doctors and hospitals. Moving away from the fee for service payment system toward bundled patients and capitation where feasible would also be helpful.
    Finally, I think we need to do a better job of educating patients that more care is not necessarily better care and sometimes it leads to worse outcomes. Too many patients perceive doctors who order lots of tests as “thorough.” Even a doctor who orders a test he or she knows is probably unnecessary cannot tell us precisely how much of that decision was motivated by defensive medicine, how much was money driven, and how much was trying to satisfy sometimes unreasonable or inappropriate patient expectations. Tort reform as I define it is not a silver bullet that would rein in healthcare costs. Indeed, there is no silver bullet. There are lots of silver pebbles, however, and tort reform, I think, is one of them.

  37. This is getting off topic, but Barry, what do you think of the evidence that fixing the tort system doesn’t lower medical costs or change practice patterns? There have been several states, notably Texas, that have undergone tort reform and it doesn’t seem to have affected what physicians do at all.

  38. Margalit – A VAT IS taxation and widely used across Europe. I assume you prefer either higher general income taxes or a payroll tax to fund health insurance. I think any tax based system needs to be as visible and transparent as possible so everyone understands exactly how much they are paying for health insurance – their own and everyone else’s.
    As for “waste,” it’s in the eye of the beholder, of course. Presumably, the USPSTF would characterize mammography screening of 40-49 year old women as well as women older than 74 as “waste.” Aside from outright fraud such as billing for services never provided, you would be hard pressed to find agreement among providers or patients as to what constitutes waste.
    Our medical prices are considerably higher than elsewhere as jd notes on another thread. Doctors’ incomes are twice as high here as elsewhere. Our hospitals are more elaborate and more expensive to build and operate. We have more equipment such as sophisticated imaging machines. Brand name drug prices are considerably higher here, though generics are actually cheaper than in other countries.
    The high CEO compensation makes a good sound bite but is a non-factor. If the top 25 or even 50 executives of every health insurer all worked for free or $1.00 per year, the aggregate savings would lower health insurance premiums by a fraction of 1% at most. Besides, much of senior executive compensation at for profit companies is in the form of stock options and restricted stock. The cost of these awards is generally not paid for by customers. It is paid for by shareholders in the form of earnings per share dilution. Moreover, over 40% of the private health insurance market is controlled by NON-PROFIT insurers. Their average net profit margin is 1%-2% of revenues at most.
    Hospital charges, by contrast are astronomical. Yet, 85% of the hospital beds in this country are owned by NON-PROFIT institutions. The non-profit market share is 100% in the high cost cities of NYC and Boston.
    Beyond going after fraud much more aggressively, I think a brighter light needs to be shined on the tort system and the defensive medicine that results from it as well as often unreasonable and unrealistic patient expectations including expectations related to end of life care. At the end of the day, the enemy is US.

  39. Actually Barry, the numbers were for illustrative purpose only and not intended as exact measures.
    The point being that it would be better to get rid of all the waste and fraud and excessive profits and salaries across the board, before we start rationing care. There is something morally wrong with doing it in reverse order.
    By the way, I like Dr. Emanuel’s proposal much better than one public plan (not the VAT part, I prefer taxation).

  40. When my wife went for her most recent annual mammogram, in talking with a staff member, she learned that the most difficult patients to handle at that center were the elderly Alzheimer’s patients. Even though doctors generally advise that it is no longer necessary for these women to be screened for breast cancer, their husbands bring them in for the test anyway, mainly out of a sense of duty apparently. I wonder how many of these mammograms would not be performed if the patient and/or the family had to pay out of pocket even though the cost is far from prohibitive. This is just another example that shows how freely healthcare dollars are spent when someone else is paying.

  41. Thirty percent of health insurance claims aren’t honored by insurance companies. If you don’t have insurance you’re probably not getting any tests in the first place.
    Tests tell you two things about cancer. Either it’s a fast moving cancer or it’s not. If it’s a fast moving cancer it’s too late. If it’s a slow moving cancer it doesn’t matter. Doctors picking at tumors and radiation are meaningless wanderings. If a growth is causing symptoms then and only then should it be removed. Modern techiques spread the cancer cells.
    One of the oldest sharpest people on Earth has a brain tumor her whole life. She is well over 100. She would be dead if she had the wrong doctor. She wouldn’t have died from the cancer. She would have died from the health care system we have today.

  42. “If we have $1 to spend on health care, we are first told to take one quarter and throw it down the drain. Then we are asked to take another quarter and give it to the guardians of free markets, such as insurers, pharma and device companies.”
    Margalit – I assume your first quarter refers to administrative costs. This is the same misinformation we keep hearing from Physicians for a National Health Plan (PNHP) and the California Nurses Association among other single payer zealots. Their administrative cost claims have been debunked many times including by liberals like Maggie Mahar. A good large employer self-funded plan has administrative expenses of 5%-11% of total spending. A physician practice that contracts out its billing function is charged roughly 5% of revenue actually collected with high billing specialists and surgeons charged less. Hospital costs that have anything to do with billing or dealing with insurers amount to no more than 1%-2% of revenue. Administrative costs are high as a percentage of the premium (as much as 30%) in the individual insurance market which covers about 18 million people and accounts for, perhaps, 5% of private insurance premium revenue. Most large insurers will tell you that their average premium in this market is about $2,500 per year per person or bit over $200 per member per month (PMPM). Private insurance premiums including spending by self-funded employers cover only about 35% of healthcare costs. The rest is paid by Medicare, Medicaid, other government (DOD, VA, etc.), individual out-of-pocket spending, and philanthropy.
    Most experts that have looked at this conclude that a switch to a single payer system might save between 2% and 5% of healthcare costs and that would be only a one time saving. It would do nothing to impact the medical cost growth curve. At the same time, medical experts including Dr. Ezekiel Emanuel, brother of Obama Chief of Staff, Rahm Emanuel, and a member of the Administration himself, tell us that a single payer system would drastically curtail choice and have an adverse effect on competition and medical innovation. For the record, he favors a voucher approach funded by a dedicated Value Added Tax (VAT).
    Regarding your comment about limiting drug and device manufacturers to a 15% gross margin, I think you know better. These are high risk R&D and asset intensive businesses. Even a low capital intensity business like supermarkets has a gross margin in the mid to high 20’s. The latest data that I’ve seen shows that 66% of all prescriptions in the U.S. are now generics though they account for only about 20% of the dollars spent or a bit less. Two blockbuster drugs, Lipitor and Plavix, go off patent in 2011 and 2012, respectively. Those are two of the top three drugs by sales in the U.S. The future of new drug development will likely be focused on highly specialized cancer treatments which are very expensive. Hopefully, advances in genetic testing will allow doctors to better match specific drug therapies to the individual patients most likely to benefit from them. This is high risk, expensive stuff that requires the prospect of an acceptable return to attract the capital necessary to fund it.
    The bottom line is that we absolutely need to take cost into account in deciding what insurance, whether public or private, should pay for and the sooner the better. People who want things that aren’t covered can self-pay. As I said in my prior comment, resources are finite. We should accept it and deal with it like we do in all other parts of our economy.

  43. And you are surprised at this reaction?
    There is no serious effort here to reform anything. This is all about expanding coverage and then saying we did it, we reform health care in America and then when the deficit gets worse by the year, most of the politicians doing this will no longer be in office.
    If you want to see why we cannot control health care costs or change the system for the better, check out my latest blog article. I know physicians will relate to this perspective which is based on my 48 years managing health benefits for a Fortune 500 company.
    I also have an article addressing the logic on the topic of guidelines and the coming debate over each and every change.
    It’s a losing battle folks as we are reinforcing all the bad habits and perspectives and cannot demonstrate the political courage to do it right.

  44. Well then Peter, how about having health care come out of our taxes as well? Would it change the frame of mind? I doubt it, but it’s worth a try.
    I have several problems with the mammogram debate:
    There may be clinical reasons for not having routine mammograms before the age of 50, as Greg describes in detail, in which case we should probably not have them done.
    The argument that although they do save lives, they are not cost effective and we have FINITE RESOURCES is a bit out of order, I believe.
    If we have $1 to spend on health care, we are first told to take one quarter and throw it down the drain. Then we are asked to take another quarter and give it to the guardians of free markets, such as insurers, pharma and device companies.
    Now that we only have 50 cents lefts, we are told that we cannot possibly afford to buy what we need.
    So before we go figuring out what we can afford to buy for 50 cents, I would like to put an end to wasting quarters down the drain and I would like the corporations to learn to live with less, just like all of us, and make do with only 15 cents gross margin.
    When all that is done, and not one minute before, we’ll look at our 85 cents and see what it buys.
    Who knows, maybe it will turn out that we can afford mammograms for those that want them. Maybe we can even afford all those Viagra and Cialis prescriptions…..

  45. “I’m sure we could save a life here and there if routine mammograms were covered for the 20 year old crowd.”
    Only in healthcare do people expect and want others to pay for every life to be saved. No where else in society does cost not matter. How many more lives could be saved if we spent double on our police force, our ambulances and paramedics, what about spending double on building our houses to get zero risk of fire. Why don’t we spend double on womens crisis centers, that would save lives too, or at risk children to prevent future murders. BECAUSE it comes directly out of our local taxes and we fight to stop increases in taxes that come directly out of our wallets. Thank you Greg Pawelski for giving us some reasoned analysis and facts.

  46. “Finally, under reform it is extremely unlikely that insurers (including the public plan) will stop covering treatments and tests (including PSA tests), that have been in use for a long time. More likely, they will lift co-pays and lower reimbursements for procedures that are less effective, while lowering co-pays and lifting reimbursements for procedures that the medical evidence shows are more effective.”
    Actually, I think this is probably a reasonable middle ground. As I understand it, there are many preventive tests for which the USPSTF assigns a letter grade of A, B, C, D or F based primarily on a benefit vs. potential harm criteria. I’m not sure to what extent cost-effectiveness plays a role in determining the rating. At any rate, such a grading approach would lend itself quite well to insurance co-pay tiering like we’ve been using quite effectively for prescription drug coverage for some time now.
    Since most other countries already use the criteria recently suggested by the USPSTF, it would be interesting to compare the death rates from breast cancer per 100,000 population for women in the 40-49 age cohort as well as the 50-74 group in the U.S. vs. Canada, UK, France, Germany, Sweden, and Japan among others. The data should be especially useful because, according to a New York Times article published within the last two weeks, none of the standard healthy lifestyle choices including maintaining a normal weight, following a sensible diet including plenty of fiber and fruits and vegetables, getting adequate exercise and drinking in moderation, while great for preventing diabetes and heart disease, have shown no evidence of preventing cancer. The only significant exception is to quit smoking or never smoke in the first place. As it happens, the percentage of the U.S. population who smoke is the second lowest in the world after Canada.
    Personally, if we ever expect to control healthcare costs, we will have to take cost-effectiveness into account when determining coverage and payment policy. Nobody is going to stop anyone from spending their own money for uncovered services. With respect to breast cancer, as others have noted, women get breast cancer in their 20’s and 30’s but we don’t start screening at 21. It should be obvious to anyone with an IQ above 50 that RESOURCES ARE FINITE. We have to make some choices that are sometimes difficult.

  47. The U.S. Senate is expected to vote at 8pm tonight to determine whether debate can go forward on Senate Majority Leader Harry Reid’s 2,074-page bill to dramatically change the U.S. health care system. This could be one of the most important votes in the history of our country. I sent an email to Virginia Senator Jim Webb’s office this morning that I would like to share with you today. I encourage all Americans to contact their Senators immediately because time is running out. The vote is scheduled for tonight America. Join me. Stop freedom’s demise!
    See my blogcast here:

  48. The other side of the coin, presented to me from an oncologist friend, is radiation risk imposed by mammography, is not simply of negligible value in younger women, but may have a net harm effect, if women who have mammograms at age 40 start having higher rates of cancer in irradiated breasts 25 or 35 years later.
    The recommendation not to begin mammography until age 50 has to do with medical issues, more than cost effectiveness issues. Mammography is not harmless. You are subjecting women to annual doses of ionizing radiation to the breasts, with some unavoidable scatter to chest wall and lungs. We do not know how many women who are irradiated by mammography in their 40s will develop radiation-induced breast cancer (or even lung cancer) in their 60s, 70s, and 80s.
    The other problem is that women in their 40s tend to have very dense breasts, making it more difficult to get an accurate exam. These women often are called back for additional views, giving them even more radiation. There are more false positives, leading to breast biopsies and sometimes unnecessary lumpectomies, in cases where the biopsies are technically suboptimal.
    In contrast, in older women, their breasts are less dense, making the examination more accurate, with fewer false positives, and there are fewer years of remaining life to develop a radiation-induced malignancy.
    The fact is that we have no truly long term follow up studies to determine very long term risks of carcinogenesis from radiation exposure in mammography.
    1. J Radiol Prot. 2009 Jun;29(2A):A123-32. Epub 2009 May 19.
    Mammography-oncogenecity at low doses.
    Heyes GJ, Mill AJ, Charles MW.
    Department of Medical Physics, University Hospital Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK.
    Controversy exists regarding the biological effectiveness of low energy x-rays used for mammography breast screening. Recent radiobiology studies have provided compelling evidence that these low energy x-rays may be 4.42 +/- 2.02 times more effective in causing mutational damage than higher energy x-rays.
    The risk/benefit analysis, however, implies the need for caution for women screened under the age of 50, and particularly for those with a family history (and therefore a likely genetic susceptibility) of breast cancer. In vitro radiobiological data are generally acquired at high doses, and there are different extrapolation mechanisms to the low doses seen clinically. Recent low dose in vitro data have indicated a potential suppressive effect at very low dose rates and doses. Whilst mammography is a low dose exposure, it is not a low dose rate examination, and protraction of dose should not be confused with fractionation. Although there is potential for a suppressive effect at low doses, recent epidemiological data, and several international radiation riskassessments, continue to promote the linear no-threshold (LNT) model.

  49. More on Mammograms–and Conservative Opposition to “Comparative Effectiveness” Research by Maggie Mahar at the Heat Beat blog.
    The news about mammograms is not brand new information based on one study that just came out. The recommendations that the Preventive Services Task Force (PSTF) released is based on research that experts have known about for some time.
    Dr. Herman Kattlove, a retired medical oncologist did research on mammograms in the early 1990’s. For seven years, until his retirement in 2006, Kattlove had served as a medical editor for the American Cancer Society where he had helped develop much of the information about specific cancers that is posted on the society’s website.
    On his own personal cancer blog, Kattlove wrote, “Many years ago, the National Cancer Institute (NCI) tried to convince us all to not screen women younger than 50 and were given such a tongue lashing by Congress that they went home, licking their wounds, and withdrew their recommendation.”
    Of course, Congress should not have become involved in telling the NCI what information it should make available to the public. Few Congressmen are either M.D.s or scientists trained to analyze and critique medical research. But this illustrates just how politically charged the question of diagnostic testing has become, especially when companies like GE that are making large profits on the sale of diagnostic testing equipment, and their lobbyists are helping to finance Congressional campaigns.
    For decades doctors have urged patients to undergo mammograms because they sincerely believed that mammograms saved many lives. They, too, were not receiving all of the information they needed about the risks. Powerful forces stood in the way of widespread dissemination while millions of dollars were poured into the Mammogram campaign.
    Kattlove goes on to say, “Likewise, the American Cancer Society also avoids looking clearly at the data and continues to recommend screening for younger women. And the morning’s paper carried lots of outrage from breast cancer specialists and other docs who are committed to screening younger women.
    Some of the reasons for this are political and financial. The ACS doesn’t want to enrage its donor base, Congress didn’t want to upset constituents and breast cancer specialists have faith in the procedure. I’m sure all the pink breast cancer organizations are also organizing their protest.
    Why this emotion and outrage? I think because we feel helpless when we see women die of breast cancer, sometimes while still young. Indeed, deaths in these young women hit us hard. So we want to do something and our only tool is mammography.
    “But mammography is not the answer for these women.” As Kattlove points out in his post, when young women die of breast cancer they are usually killed by very fast-growing aggressive cancers that grow too quickly to be caught by early detection. The tumors crop up, and spread in between annual mammograms. Kattlove continues: “The unfortunate side effect of this delusion [that screening and early detection is the answer] is that we avoid the hard choices like healthy life styles and avoiding cancer-causing drugs such as hormone-replacement treatment.
    I would add that while I applaud the PSTF for bringing this research to our attention, I wish that they had done this two or three years ago. From a political point of view, the timing is unfortunate because inevitably, those who oppose health care reform will exploit this report to suggest that, under reform, the Government will use “comparative effectiveness research” to deny necessary care—and as a result patients will die.
    In fact, health care reformers, the government and Medicare understand that, after thirty years of telling women that they must have annual mammograms, we cannot turn on a dime and expect them to suddenly absorb the information that for most average-risk women under 50, mammograms pose more risks than benefits.
    No one is going to stop covering mammograms. But responsible physicians will begin giving patients more information about what the medical research shows, including the fact that for most women, the danger of undergoing unnecessary radiation, or an unneeded mastectomy or lumpectomy, far exceeds the likelihood that a mammogram will save their lives.
    Moreover, it is important to remember that the “comparative effectiveness information” that the government plans to generate will serve to create guidelines—not “rules”—for doctors. In the U.K., doctors use such guidelines about 88 percent of the time, which seems appropriate, giving how much variation there can be in individual cases.
    Finally, under reform it is extremely unlikely that insurers (including the public plan) will stop covering treatments and tests (including PSA tests), that have been in use for a long time. More likely, they will lift co-pays and lower reimbursements for procedures that are less effective, while lowering co-pays and lifting reimbursements for procedures that the medical evidence shows are more effective.
    In this case, unfortunately, we don’t yet have a good alternative to mammograms, a further reason why insurers will not suddenly stop covering the tests.

  50. Peter, there are two distinct concerns to address here, clinical and financial, and I am not sure which one the USPSTF was tasked to address, but I believe, as Bev wrote, it was the former.
    I believe guide lines come in two flavors and probably always will: purely clinical advice based on evidence with the final decision left to the doctor/patient team with no financial consequences, and the coverage rulings where the decision, while still left to the doctor/patient combo, carries financial implications.
    AHRQ is funding and accepting many studies and some end up in the clearinghouse (NGC) as published guide lines after proper review. So the process for adopting a purely advisory clinical guide line is there. What I cannot seem to find anywhere is a process to translate a particular guide line into a financial coverage decision by CMS.
    What happened with the USPSTF report was that people assumed that the report was representing coverage decisions. Bev is right, it was not. None of the AHRQ guide lines do.
    And by the way, this new report is not much different than the ACP recommendation from 2007.
    When a guide line report gets translated into restriction of coverage, it becomes a “death panel” and the forum that performs that translation is the “panel”.
    So effectively, we already have plenty of death panels, since no insurer covers everything that may save lives in rare occurrences. I’m sure we could save a life here and there if routine mammograms were covered for the 20 year old crowd.
    The problem is that there is no formal process for translating guide lines into coverage decisions. The big problem is that if we attempt to define and formalize such process, it will be inevitably and foolishly represented as creation of death panels.
    I am not at all certain how to solve this problem, but I would try two things. One is a public education campaign explaining the need for coverage decisions to be made in full public view, instead of little dark rooms of various insurers. The second one would be to call on our physicians to exercise responsibility and be mindful of the guide lines in their practice. Cost containment in the current environment is impossible without physicians’ cooperation.

  51. “There’s got to be a more robust process defined for dealing with studies and applying findings to coverage policy.”
    What would you like to see? What agenda do you think AHRQ has?
    Here are their RECOMMENDATIONS: Pretty mild stuff.
    Note, these recommendations DON’T override a decision by an individual patient or doctor that would apply to their distinct situation.
    “I don’t know of anything that’s in place right now other than going with whoever yells louder.”
    Well it seems that those who want all the healthcare other people pay for and those who want to treat all the health problems other people pay for are yelling the loudest. Margalit, how do you expect the system to control costs if we just listen to the “death panel” extremists?

  52. Population statistics have never applied to the individual. This is why each patient should keep his own money and buy what healthcare he/she WANTS and NOT buy other people’s care for their wants.

  53. Peter, I don’t understand the expectations here. This is just another report and it needs to be reviewed and analyzed (see the response from NCI).
    What exactly were people expecting? An immediate announcement from CMS that Medicare will stop paying for mammograms for women younger than 50?
    There’s got to be a more robust process defined for dealing with studies and applying findings to coverage policy. I don’t know of anything that’s in place right now other than going with whoever yells louder.

  54. “Who exactly is qualified to pick the opinion of USPSTF over the opinion of the American Cancer Society?”
    The ACS is not paying the bills and also has it’s own political agenda on rejecting anything but give til you drop and spend til you drop on cancer. I also say that you can kiss the so called savings from the “health reform” bill out the window when the administration caves so easily on a minor issue as this. It’s mob rule on healthcare.

  55. Margalit:
    The American Cancer Society is “well respected” as a great fund raiser. They have an enormous financial stake in maintaining the status quo. Please don’t present them as an objective source. They are a major player in the breast cancer industry.

  56. The task force didn’t do a cost effective study, they did a comparative effectiveness study. And they concluded, based on evidence, that the risk outweighed the benefits for “routine” mamm under 50.

  57. Regardless of which “effectiveness” they’re talking about, it was bunch of people trained in medical statistics just doing their scientific thing, and Obama and his pals immediately condemned their conclusions went back to True Belief to justify just doing the same old thing. That in itself was hilarious, but even more hilarious is the fact that this is exactly what will be happening under government-controlled socialized medicine, in far more heavy-handed form. You think cutting back on mammograms before 40 is terrible? Wait until you are denied getting one after 65. Wait until you are denied surgery after 70. And I love that they want to tax “cosmetic surgery” – as in breast reconstruction after cancer surgery. Can’t wait to hear the screaming about that one.
    The guaranteed way to avoid all this: a system based entirely on individual policies, chosen by individuals not employers or the government. Owned solely by individuals. If you want yearly mammograms, you’ll buy a policy that includes them. It will be the choice of the consumer, not some government bureaucrats.

  58. Merrill, good post, but what you and most everyone else aren’t mentioning is that the dispute over the new mammography recommendations shows the widespread hostility to COST-EFFECTIVENESS analysis, not necessarily toward comparative effective research. These are two separate but related things. As you know, Medicare and private payers explicitly base some coverage decisions on CER but no one has had the guts to openly use cost-effectiveness calculations. The mammography brouhaha is one more example of why everyone shies away from considering cost.

  59. No, no, NO! Comparative effectiveness research, in its original formulation, has nothing to do with cost effectiveness. It compares one treatment to another to see what works better. This is how the discovery was made that coronary stents are not an improvement over optimal medical therapy in patients with stable coronary artery disease, for instance. (And, I believe, subject to more complications, although this is not my specialty). And that coronary bypass surgery is actually superior to stents in patients with certain types of coronary lesions.
    It is our politicians and the media who have inextricably, and now fatally, linked comparative effectiveness research to cost effectiveness. You do not understand what an opportunity has been lost here. All medical research will now be viewed through this distorted lens. We will all be the losers for it, but it is too late now.

  60. What astonishes me most about all of this is that some bonehead decided that this was an appropriate time to release this study! If I were in the administration I’d consider investigating this as aggressively as the leaks about discussions concerning strategy in Afghanistan. I guess I’d be called a conspiracy nut if I suggested that some shady business may have been involved….

  61. Anon- You will have an impossible time finding a test or procedure that has unanimous support to be of no benefit or harmful because many tests and procedures are money-makers for the industry. You assume no physician would perform a procedure on a patient that’s harmful or has no benefit? Anon, you would be wrong, it happens all the time. That’s part of the problem. Your faith is in a failed system.

  62. Merrill,
    I have to say that I really agree with your blog entry here. I, too, feel like this was a punt and a huge missed opportunity by the Obama administration, and that the politics of Comparative Effectiveness was definitely hovering behind a lot of this controversy. I posted some similar thoughts last night at http://blogs.intel.com/healthcare.
    This would have been–and could still be–a great teachable moment about the economics, evidence, and emotions of healthcare. I see today many headlines about other health screening recommendations coming out (PAP tests, for example), and I’m afraid that now every one of these is going to be politicized in ways we have never seen before. What used to be technical reports and updates by medical expert committees is now getting Internet and media scrutiny, and is being used in extreme ways to play upon fears and facts to achieve other political ends. Sad times.

  63. To respond to your other point, I call it “potentially inflammatory” because I dislike exaggerating or unrealistic hypotheticals as a debate strategy. Also, it tends to bring out emotional, debate inhibiting responses and people miss the point (I’m glad you got it Lisa).
    Mammograms, by the way, are a relatively easy example to be firm and argue that if they aren’t covered every single year if you are in you 40s, and you still want one, just go out and buy it. Imagine how more difficult the discussion becomes if we were talking about, say, a questionable knee arthroscopy given a diagnosis of arthritis? Now an insurer decision to not cover it effectively means that 90% of patients can’t afford to go out and buy it on their own. I don’t care if you have pain and you think it will help.
    Again this supports my argument to have the insurer pay for at least some of it. Who knows, maybe it was all in the patient’s head anyway but the surgery could actually “do” something for some patients to ease their joint pain.

  64. I think that in an uncertain clinical landscape, CMS/Insurers may have to foot some of the bill because deciding what is necessary/unnecessary is not black and white. It is a bit of a compromise to acknowledge that we don’t know everything. Under value based design, out of pocket expenses for services/tests that are proven to be of high clinical value should be very low or nothing. Out of pocket costs for those services/tests for which there is unclear clinical value should be higher (or at least higher than substitute procedures/tests of higher value). For totally worthless procedures/tests, there should be no coverage. However, I struggle to come up with one example of a test/procedure that has been proven (with unanimous support) to be of no benefit or harmful in every case. If there were, I assume no physicians would be doing/prescribing them. Unfortunately, the clinical research or comparative effectiveness to determine what tests/procedures are higher value has not been done to the universe of medical practice, so there are a lot of blind spots.

  65. Anonymous, taking it to the absurd extent isn’t inflammatory, it’s highlighting the absurdity of defending unneccesary medical procedures. Dr. Motew makes an excellent and rational point.
    Back to anonymous, why should CMS, or the general public, foot any part of the bill for unnecessary, ineffective medical procedures?

  66. The important point is perhaps the surpassing of a public policy declaration by individual pressure. The current mammography discussion is only one of MANY potential targets for cost and safety containment.
    While the data needs a little more debate, the gist of the USPSTF recommendation is that at the population (not individual)level, there is more harm than good as measured by exam risk, detection rate and survival.
    But, talk to the rare 34 year old who demanded ‘routine’ mammography from her employer and whose life was subsequently saved by early detection and now you have a 100% screening success rate. This makes global policy declaration difficult in the land of individual voters,politics, etc.
    In a publicly supported (ie paid for)health care system, cost containment MUST rely on some population-based decisions. Those individuals who want to surpass this, can pay for it some other way. Take the same low-risk 34 year old, and ask her to foot the bill and she can decide if the risks, detection rate and survivability are worth it to her and thus alleviate the cost issue. For those who can’t afford it, then the population-based policy is the best they will get.

  67. What people sometimes fail to understand, or acknowledge, is that there isn’t one “sanctified” body that does all the research and releases all guide lines. There are multiple entities, many equally qualified and respected, emitting study results, with very often conflicting results and conclusions.
    Who exactly is qualified to pick the opinion of USPSTF over the opinion of the American Cancer Society?
    What is the process of changing established guide lines? And for that matter what is the process for creating new national guide lines?
    What is the process for reconciling conflicting study results and creating national guide lines?
    It is one thing to say that we should follow evidence based guide lines, and quite another to actually define the implementation.
    Let’s try a bit of speculative discovery here: If USPSTF would have come up with recommendations to start screenings at the age of 30 and ACS would have opposed that and Secretary Sebelius would have stuck with the existing ACS guide lines for now, would the same folks attacking her now would defend her stance?
    If the answer is no, then I guess we should just place all the studies in chronological order and switch guide lines every time there’s a new one.
    If the answer is yes, then I assume we should only follow guide lines that cut costs and disregard the other ones.
    The only lesson learned from this “storm” is that we have no mechanism to implement creation and adoption of evidence based guide lines and we better get to work on the non glamorous nitty-gritty details sooner rather than later.

  68. Peter, you’re barking up the wrong horse. Forget – just for the moment, just for the exercise – the individuals involved; look at the financing mechanism differently.
    Take the crude analogue of pollution abatement credits cap & trade, and run with it.
    Here, I’ll help you with the 1st steps. Let’s draw up a crude model to keep it simple. Here are the parts:
    1) Uber-Body (national, international) committed to supporting “Better Health For All the Realm”.
    2) A Threshold Personal Health Level Index, devised by or for the Uber-Body. The index will be designed to provide a baseline against which each individual’s probable health over the index maturity (2 years, or 5, or 10: there may be many ‘right’ maturity terms) can be “parred”.
    3) A mechanism for pricing the value of PHLI’s under/over par
    4) qualification terms for aggregators/securities packagers & issuers of PHLI-backed securities
    5) Market rules/terms for trading PHIL-backed securities
    The goal is not to spin up a Rube Goldberg financing mechanism so much as to
    1) imagine a more transparent picture of what currently exists, AND
    2) re-set incentives so the reward is not simply for signing up & keeping a bigger share of healthy people (or more importantly, healthy premiums or claims payers)on the rolls, but for maintaining and improving that population’s health over time.
    One distinction between this fanciful model and what exists now is that it can be more transparent (because the population’s risks are “known”, measurable and independently assessible, however accurately), and much more about preserving & improving the health of people whose physical mental & financial health is entrusted to it.
    I have a feeling it also suggests a bridge between the desire for an equitable way of making sure those with significant health care challenges are not marginalized for financial (the free market risk) reasons, and those who insist that a government-run health mechanism will marginalize those same people for political reasons (you go ahead & bring up the revised cancer screenings recommendations – I’m sure not going to). This imagined alternative provides an opportunity to shift incentives to doing something good for peoples’ health across the board, rather than focusing rewards on the avoidance of peoples’ illnesses & injuries.
    Nate would even have a chance to be justly rewarded for his adept management of a ‘gilt-edged health index securities portfolio’! What’s not to like?

  69. The prevailing ill-formed logic that if it saves even one life it is worth every expense and side effect is what got us into this mess to begin with. By taking that same logic to it’s absurd fullest, I could argue that every woman should have a double mastectomy. That is guaranteed to eliminate deaths related to breast cancer too. Damn the cost or uselessness or side effects.
    Switching from potentially inflammatory to constructive, value based benefit designs are a way to compromise on black-and-white coverage policy. If the mammography is appropriate according to evidence-based guidelines (whatever those may be), it is covered 100%. If it is not, you can still have one but the patient is responsible for 50% of the cost. No one is saying you can’t have the mammography, but don’t expect CMS or insurance to foot the bill if it isn’t really needed.

  70. Margalit, it’s been more than 24 hours since the scientific community determined routine mammographies are over-used. This actually isn’t “new.” Further, there is no evidence that arbitrary, routine mammographies in women with no other symptoms or family history, is saving lives. It’s an early detection tool and should be used effectively for that purpose. Merrill Goozner is correct, we should provide mamms to every woman that needs one, or is in a high-risk group, not just every woman for the hellofit. I finally understand what “bleeding heart liberal” means.

  71. I fail to see how this is an indictment of comparative effectiveness. There was one study published recommending a change in guide lines. Guide lines that have been in effect for many years and created by well respected authorities such as the American Cancer Society.
    On top of that, there is measured and documented success in combating the disease, while these guide lines have been in effect, as shown by the decline in mortality rates. Whether these particular guide lines are responsible for the success, or have nothing to do with it, or are only partially accountable, is unclear, i.e. there is no quantifiable research, only speculation and opinion.
    So what exactly are the expectations here? Should the entire medical and administrative field change their practice 24 hours after each new study shown to save money, is published?
    Shouldn’t there be a review period? Shouldn’t new studies always be met with skepticism, as is common in every scientific field, particularly when flying in the face of established practice?
    I think Secretary Sebelius did exactly what she should have done, exactly what every self respecting scientist would have done.
    This doesn’t mean that we are rejecting the notion of evidence-based guide lines. It means that we insist that the evidence be rock solid before we go risking even one life.

  72. My first reading about this story was in the Chicago Tribune which got reaction quotes from “everyone”. Apparently “everyone” is represented by 3 radiologists and a breast cancer survivor. Sounds like a good balanced sample of people to interview, right?
    That said, this is a very bad time, politically, to show the messiness of actually using comparative effectiveness studies to change policy and evidence-based clinical guidelines. If HHS said they were going to change CMS coverage policy, it would destroy all hope of health reform by providing ammunition that the government is going to ration health care. They should have just held on to this study until after some reform was passed.

  73. This issue shows a failure of leadership from those who purport to be healthcare leaders. Johns Hopkins FAIL. Memorial Sloan Kettering FAIL. Breastcancer.org FAIL. Until these other entities fully disclose their financial interests I cannot respect them.
    The behind the scenes conversations for these folks included detailed discussions concerning the financial impact on their businesses. I demand that in addition to their highly public comments, Marisa Weiss (Breastcancer.org) Lillie Shockney & Nagi Khouri (Johns Hopkins), David Dershaw (Memorial Sloan Kettering) and all the others also provide the precise financial impact of the newly recommended guidelines. They can reveal the retrospective analysis they have already done showing the # of women age 40-50, & # of women age 75+ (without other risk factors) that have been screened, treated unnecessarily and radiated for low-grade DCIS, in each of the past five years and what that represents in terms of % of revenue.
    If they were true leaders they would use their clout to rationally discuss the subtleties of the guidelines.
    I have now lost all faith with medicine. When the leaders ignore the science what hope is there?
    These “leaders” are protecting their investments, not women.

  74. Why stop at mammography? Everybody should get an annual chest x-ray, whether there is any medical indication they need it or not. And an MRI, plus CT Scan. Why stop there, everybody should get a prescription for any medication they want to take. Whether they need it or not. It might hurt them, but it might help them and who are we to deny anybody anything that might help them? Wait, we really should have all access. Everybody should be entitled to exploratory surgery on an annual basis. Cut us open and take a look, we might have a problem and we shouldn’t be denied this inspection whether it hurts us or helps us. And don’t forget the annual HYDA scan, a minor nuclear test to make sure our plumbing is functioning. Ultra sounds every 6 months. C’mon, we have a right to early detection of everything that could possibly happen to us. DNA, our DNA should be analyzed to screen for any possible future ailments we could develop, and treatment should begin promptly, before any symptoms are present.

  75. Unfortunately, the real golden opportunity here is to educate those concerned with public health decisions about the realities of government guided health care: it is a political process.
    Many of us would like to think, would like to expect, that government decisions would be based on science. Sometimes they are. But if there is a political effect (and there almost always is) the decisions will be at least biased by political calculations (and, at worst, decided by political considerations regardless of the science).
    It is a fantasy to think, plan, propose, or expect otherwise. It is stupidity to think further steps to manage health care by government fiat will not make things worse than they already are.

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