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Helping Each Other Take Care of Each Other

May 29, 2009• 2

By STEVE ADAMS

How many billions of dollars in volunteer health care services are donated in this country?
How can HIT stimulus dollars help to provide development of businesses or business models that provide an economic multiplier effect to the value of volunteer health services work?
How can volunteer health care services be attached to the coordinated care team? (Clinicians, family, friends, volunteers)

I attended a “Health Fair” today. I confess that it is the first one I have experienced. While I have been working in health care information technology longer than I will admit, I have been aware of “health fairs” but never actually participated. I have always been able to afford health insurance throughout my adult life and in my childhood my parents had access to employer sponsored health coverage. When I am due for a check up or need other attention to my aging body, I have been quite fortunate to have very talented and dedicated physicians and other providers who accommodate me and take care of me.

Workers Ungrateful for Empowerment to Pay More

May 28, 2009• 24

By MICHAEL MILLENSON

American workers sure are ungrateful.A new report by the National Business Group on Health (NBGH) says that 27 percent of insured workers are skipping health care treatments to avoid co-payments, 20 percent of employees are not taking their prescriptions as advised by their doctors, and 17 percent of employees are cutting their pills in half to make them last longer.Yet rather than expressing gratitude for the opportunity to express their consumer-driven preferences, and rather than praising the benefits consultants and conservative think-tank talkers who have given them the chance to have “skin in the game,” 58 percent of those surveyed said they “continue to be surprised” at their out-of-pocket costs. Obviously, they haven’t been attending conferences of HR execs, or they’d know that one man’s “cost shifting” is another man’s “empowerment of my employees.”It turns out that shopping for health care is not like shopping for a refrigerator and that changing co-pays and deductibles has to be undertaken with a great deal of care. Workers, hard-pressed financially by a deep recession, workers are not craftily eliminating unnecessary and non-evidence-based care. Instead, they’re pill splitting or skipping the pills entirely. This is precisely what the landmark RAND Health Insurance Experiment research on copayments and deductibles predicted more than two decades ago, which would be no surprise had the study consistently been quoted honestly by all proponents of the so-called consumer-driven health plans.

Of course, what goes around, comes around. Since 68 percent of employees say that having access to health benefits is a key reason for staying with their employer, it will be that same employer who picks up the tab for the consumer-driven diabetic who has to drive her consumer self to the emergency room because she couldn’t afford her medication. However, the good news is that a majority of workers polled said financial incentives from their employers have motivated them to try to lead a healthier lifestyle.In fact, about half of workers now agree that fat people and smokers ought to pay higher premiums. That’s only fair. And I think guys who have personal trainers and executive physicals should pay less, too, don’t you? Oh, wait. That wasn’t on the questionnaire.Why not just eliminate health insurance altogether and instead give every worker a shiny apple a day? (To keep the doctor away, of course.) If any HR execs, benefits consultants or conservative policy wonks out there would like to adopt this proposal, you can call it One More Fruity Idea for Health Care.

The Great $2 Billion Cost Cut “Promise” Meets Another Obstacle

May 28, 2009• 16

By ROGER COLLIER

It turns out that the hospital, insurance and pharmaceutical organizations who announced with great fanfare a couple of weeks ago their plan to cut/maybe think about cutting* $2 trillion/maybe nothing* from their costs may have been even more devious/disingenuous/stupid* than was apparent at the time. [*choose one]

The New York Times pointed out yesterday that any such organized effort to reduce prices could face antitrust charges. In the Times’ words: “Antitrust lawyers say doctors, hospitals, insurance companies and drug makers will be running huge legal risks if they get together and agree on a strategy to hold down prices and reduce the growth of health spending.”

The drug manufacturer lobbyists who so eagerly participated in the May 11 meeting with President Obama should have been especially aware of the issue. Back in 1993, it was their trade group that, in an effort to soften the threat of Clintoncare, offered to limit pharmaceutical price increases to the CPI rate, then were told by the Justice Department that this would violate antitrust laws.

And, again according to the Times, it was the AHA who complained recently to the Federal Trade Commission that antitrust laws make it difficult for providers to collaborate and lower costs.

So, first these organizations promise to cut costs by $2 trillion, then they say they didn’t really mean it, and now it turns out that it would probably be illegal (which they should have been fully aware of, anyway). Who’s trying to fool whom?
Roger Collier was formerly CEO of a national health care consulting firm. His experience includes the design and implementation of innovative health care programs for HMOs, health insurers, and state and federal agencies. He is editor of Health Care REFORM UPDATE [reformupdate.blogspot.com].

Raising Legitimate Questions and Concerns About Health IT Certification, Without Getting Personal

May 27, 2009• 30

By DAVID C. KIBBE

In a recent blog post on THCB, Mark Leavitt wrote this about me: “[Dr. Kibbe’s] repeated use of falsehoods and innuendo to attack CCHIT have found an audience in the national media, reaching a level that can no longer be ignored. By implication, he demeans the integrity of everyone who has contributed to that work – and I must rise to their defense.”

The truth is that I respect both Dr. Leavitt and, equally important, the many fine people who have contributed to CCHIT work. I regret that he has made me the target of his anger about investigative reporting in the Washington Post, which I certainly did not initiate.

To clarify what I actually said, after a brief interview, quoted in the second of two articles in the Washington Post by Robert O’Harrow, Jr, a Pulitzer Prize finalist :

“One has to question whether or not a vendor-founded, -funded and -driven organization should have the exclusive right to determine what software will be bought by federal taxpayer dollars,” Kibbe said. “It’s important that the people who determine how this money is spent are disinterested and unbiased . . . Even the appearance of a conflict of interest could poison the whole process.”

Raising questions and concerns like these does not reach the level of “falsehoods and innuendo.” In my opinion, it is entirely appropriate to ask tough questions about whose interests are being served when $36 Billion of tax payers’ money is involved, and the future of health IT in the U.S. will be the result of certification.”

I am not the only one with these concerns. Many other health care and health IT professionals have raised legitimate questions about CCHIT and its practices, its relationship with HIMSS, and yet to date these have not been resolved. A response that attacks me personally and labels me a liar is far from adequate, and so the questions will remain.

The stakes are too high to simply look the other way.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies.

What’s good for General Motors is good for America

May 27, 2009• 22

By Matthew Holt

In 1953, Charles Erwin Wilson, then GM president, was named by Eisenhower as Secretary of Defense. When he was asked during the hearings before the Senate Armed Services Committee if as secretary of defense he could make a decision adverse to the interests of General Motors, Wilson answered affirmatively but added that he could not conceive of such a situation “because for years I thought what was good for the country was good for General Motors and vice versa”. Later this statement was often misquoted, suggesting that Wilson had said simply, “What’s good for General Motors is good for the country.” (From Wikipedia’s History of General Motors)

The American auto industry exploited the loophole by ramping up production of big passenger vehicles that sat on truck beds. The mini-van evolved into the the extended pick-up trucks and SUVs that proliferated during the next two decades. The American public loved the big vehicles, which were affordable because national energy policy made low gasoline prices a priority. The SUVs and trucks were hugely profitable for the manufacturers, offsetting losses incurred partly because of labor-related costs. Detroit’s dependence on these vehicles though was risky, as became clear last year when fuel prices rose steeply and the industry effectively crashed. (Peter J Boyer, The Road Ahead, The New Yorker, April 27, 2009)

This has been a tough couple of weeks for anyone believing in radical change, Obama-style. There has been unnecessary compromise over closing Gitmo and investigating torture. The lobbyists for America’s health care immediately recanted their promised voluntary cost cutbacks. The response so far from the White House has been a statement from Orszag that’s none too radical, essentially saying that bending the curve is OK.

And now there’s the revelation that some idiot at Blues of N. Carolina had already planned a smear campaign against reform, even while the AHIP crowd seems to be winning, as represented by the mealy-mouthed proposals coming out of Baucus’ committee—as Baucus himself ducks meaningful dialogue over alternatives.

So realistically, as I’ve been saying for several months, the best we can hope for from the current body politic is some kind of national exchange and a sorting out of the scummy underbelly of the individual health insurance market. (Incidentally I was watching The Rainmaker, made back in 1997, over the weekend and life has totally imitated fiction in the individual market since then—yes, I’m talking about MEGA but not just them!).

But even if we get some kind of exchange with some kind of vaguely unenforceable individual mandate and some type of guaranteed issue, the basic structure of health insurance passing through the excesses of the FFS system won’t change. Real sustainable change will only happen if we create a single universal pool and give the insurance intermediary some type of global budget, such as a fixed voucher payment per member. No one in the Baucus world or the White House, with the exception of Zeke Emmanuel is talking about that, so it’s not going to happen. And the second best choice—the establishment of a competing public plan that is budget limited—is likely to be bargained away.

So unless some secret mechanism that we’re not being told about will be sprung from the wings, realistically the best that can be done is that we’ll end up with the Massachusetts scenario. More people insured at more cost, unsustainably. And widespread practice and cost variation will continue.

The data of course tells us that on any metric you pick, spending doesn’t equal quality. Just this week the Dartmouth guys found a nil or negative correlation between spending per patient in individual hospitals and outcomes. It’s got to the point when you barely need to read the abstract on these studies. (I guess if you like you can read Atul Gawande running through the numbers yet again in this weeks New Yorker)

But if something can’t for on forever, it will stop (known as Stein’s law). Which is why I opened this piece with a reference to that wonderful New Yorker article about the meltdown in the auto industry.

The auto industry’s last two decades resulted from three irrational government policies that were kept in place by a weird combination of political forces. First, fuel prices were kept artificially low—in part by a deal between Reagan & the Saudi’s to break the Russians, and also by the reticence of American politicians to put European-level taxes on gasoline. Of course, fossil fuel producers and users didn’t have to bear the real costs of these cheap prices. But the planet and its (present & future) inhabitants do.

Second, as pointed out in the New Yorker article, the CAFE standards ridiculously excluded SUVs and mini-vans—proving that partial regulation is much worse than using taxes to do the same thing. We’re still waiting for a sensible carbon tax. Third, partial taxation is just as bad. For weird historical reasons there is a 25% tariff on foreign trucks and SUVs which means that the Japanese couldn’t compete effectively (e.g. destroy the lumbering big 3) in that market, and the big 3 could make far more profit on the SUVs than they would have done in a free market. A combination of the auto companies, the oil companies, the unthinking consumer, and bought-and-paid-for politicians enabled this to happen.

The parallels are obvious. In American health care policy, for the Big 3, substitute the AHA, PhRMA, AHIP, ADVAMED and the AMA. For the dumb carbon fuel policies, substitute an irrational employer-based insurance system with a wrap-around and uncontrolled Medicare and Medicaid system, all paying suppliers using Fee-For-Service. For the problems of global warming and pollution substitute the societal ill-effects of spending too much money on health care services that make outcomes worse, and leave less money for education, infrastructure and other more worthwhile spending. For SUVs and mini-vans substitute cardiology, orthopedics, neuro-surgery, general surgery, oncology drugs, and all the other service-lines that make hospitals profitable, but do very little for the overall health of the population. And of course the whole thing stays together because Congress is in the special interests’ pocket, the public responds well to prods from special interests (especially doctors), and it doesn’t understand the raw deal it’s getting in the bigger picture.

There’s even a parallel lies and dissemination industry. The auto and oil industries fund their “global warming is a myth crowd”, health care has Betsy McCrackers, Grace Marie Turner and the rest of the free-market nut-jobs—all on the teat of some sub-segment of the health care business which should rationally be put out to pasture.

So assuming that we don’t fix this problem in 2009, what happens when health care has its meltdown moment, or when as Alan Greene and George Lundberg like to say, the health care bubble will burst?

Lundberg argued earlier this month on THCB that there was an excessive trillion dollars spent in health care—somewhere around 40% of current spending. Actuarial firm Milliman did more work on this and suggested that we can move health care spending from the current 16% of GDP to 12%. Now they and fellow travelers like George Halvorson seem to hope that this can be done in some seamless and painless fashion. But that hardly seems realistic. Instead my scenario is that some future cataclysmic event finds the next President offering the health care industry the kind of choices that Obama has just been offering the auto industry.

Which takes me back to Boyer’s wonderful piece about the auto industry. Essentially the industry has been given extremely limited choices of how to restructure itself. They were told to:

Massively restructure their obligations to their retirees and employees
Change their work arrangements to match those of the Japanese transplant factories
Close many factories and lay-off many employees
Change their present and future product mix to reflect the worldwide energy crisis
Reeducate the buying public as to what to expect from a car (50 miles range and being plugged in nightly?)

Note that many of the Senators from “transplant states” with like Tennessee and Alabama felt pretty aggrieved that GM and Chrysler were getting all this help to compete with their “foreign” imports. Those of you who get Sen Dave Durenberger’s occasional (and prescient) health policy commentary emails may note that he frequently describes Medicare as being a redistribution mechanism whereby doctors and hosptials in high costs states like Louisiana and Florida get subsidies from taxpayers in low cost ones like Minnesota.

The way these hard choices were made at GM and Chrysler were essentially that the Treasury took over the companies and their strategy. Both the CEOs of GM and Chrysler are either gone or going, and the Federal government is directing traffic.

There isn’t quite the centralization of production in health care that there is in autos, but a 40% fall in revenues would effectively mean the government would take over the industry. So what might the equivalent of a fast GM-type restructuring look like in health care?

Massively restructure their obligations to their retirees and employees. The health care industry mostly rewards specialists, technology & pharma manufacturers, and certain segments of the hospital business. Those payment schemes would necessarily be slashed. We’re not talking about narrowing the RVU imbalance here, we’re talking about some kind of massive fee-cut backed up by a global budget cap.
Change their work arrangements to match those of the Japanese transplant factories. No prizes for guessing this. Virgin Mason and a few others have already significantly reduced all of their costs by introducing Japanese-style quality innovation process. Under current payment schemes that was a crazy thing to do. But in this scenario those hospitals and physician groups that survive would not get the choice. If the accountable health care organization, or medical home ever gets off the ground, the customary relationship of referrals from PCP to specialist and from specialist to hospital will change remarkably.
Close many factories and lay-off many employees. If you replace the word “factories” with the words imaging center, hospitals and clinics, you’re getting the picture.
Change their present and future product mix. From inpatient care and intensive procedures to prevention and primary care, with extreme makeovers in terms of chronic care process management.
Reeducate the buying public as to what to expect from a car. This may be one of the hardest parts of all. The American public regards $4 a gallon gasoline as a pestilence sent to punish them. Similarly, the move to reduce inappropriate health technology use, overhauling end of life care, and changing how people approach their health, is fraught with political peril. But the need is the same, and at some point we’re all going to have to realize that the consequences of our orgy of medical care overuse are dreadful.

Any restructuring like this will cause extreme pain. In addition, we need to make sure that the reduction in health care spending is balanced by a comparative increase in wages, or other spending. In other words, we can’t suck 3–4% out of local economies without adding it back in.

But in the end, like the auto restructuring, we desperately need this health care restructuring. And what’s now necessary for GM will end up being a good thing for both the nation’s health care system and the nation.

This doesn’t mean it will happen, or at least not soon. But one way or another, the health care system needs to share Detroit’s fate.

Coda: Mike Cassidy, San Jose Mercury News Columnist wrote a not dissimilar piece piece on Saturday which I saw on Sunday. I’d started this piece last week, so this is a case of great (?) minds thinking alike—not plagiarism, honest!

Certifying Health IT: Let’s Set the (Electronic Health) Record Straight

May 26, 2009• 90

By MARK LEAVITT

The Stimulus bill catapulted health IT – previously the domain of clinicians with a passion for applying technology to improve healthcare – onto the national stage. When you inject billions of taxpayer dollars, politics inevitably comes with it. There have been valid observations that CCHIT’s approach needs to change in this new world, and I wholeheartedly agree. But I’m stunned by the level of dishonesty a few have stooped to in a desperate attempt to toss aside years of work by hundreds of public-spirited contributors. Perhaps they want to bypass the challenge of supplying robust electronic health records and re-educating clinicians to use them meaningfully in transforming care, and just get unfettered access to some stimulus dough.

For months, I’ve been “turning the other cheek” to Dr. David Kibbe because I believe in devoting my energy to solving problems rather than to criticizing other people or worrying about what others think of me. But his repeated use of falsehoods and innuendo to attack CCHIT have found an audience in the national media, reaching a level that can no longer be ignored. By implication, he demeans the integrity of everyone who has contributed to that work – and I must rise to their defense.

David, in your most recent quote for the Washington Post, you called CCHIT a “vendor-founded, -funded and -driven organization.” So let’s take a look at the Commissioners, in chronologic order of service, who have served since our founding in 2004 — people who have been at the core of an organization you claim to be tainted:

X PRIZE Blog Rally: $10M for Health Care Innovators

May 25, 2009• 5

By THCB STAFF

Scott Shreeve, MD, Senior Health Advisor at The X Prize Foundation and frequent THCB contributor, has asked the health care blogosphere to take part in this blog rally in order to raise awareness about the Healthcare X Prize Foundation competition and encourage public participation in the prize design. Pass the word around and feel free to post this to your own blog if possible.

We are
entering an unprecedented season of change for the United States health
care system. Americans are united by their desire to fundamentally
reform our current system into one that delivers on the promise of
freedom, equity, and best outcomes for best value. In this season of
reform, we will see all kinds of ideas presented from all across the
political spectrum. Many of these ideas will be prescriptive, and don’t
harness the power of innovation to create the dramatic breakthroughs
required to create a next generation health system.

We believe there is a better way.

This
belief is founded in the idea that aligned incentives can be a powerful
way to spur innovation and seek breakthrough ideas from the most
unlikely sources. Many of the reform ideas being put forward may not
include some of the best thinking, the collective experience, and the
most meaningful ways to truly implement change. To address this issue,
the X PRIZE Foundation, along with WellPoint Inc and WellPoint Foundation as sponsor, has introduced a $10MM prize
for health care innovators to implement a new model of health. The
focus of the prize is to increase health care value by 50% in a 10,000
person community over a three year period.

I’m not sure that’s how Uwe meant it!

May 25, 2009• 6

By Matthew Holt

The AP has a puff piece on the greatness of Karen Ignagni. Well greatness if greatness is defined as doing anything it takes to screw the nation on behalf of her organization’s members, all the while telling bold face lies about their activities. But the lies of Karen Ignagni have been well documented here on THCB and we don’t need to rehash them now.

But then the AP reporter Erica Werner quotes Uwe Reinhardt and has this somewhat remarkable passage:

"Whatever AHIP pays her, it's not enough. She's unbelievably effective," said Princeton economist Uwe Reinhardt. "It's just amazing what she's achieved for them against all odds." Ignagni's total compensation, according to AHIP's most recent filing from 2007, was $1.58 million, which includes $700,000 in base salary, $370,000 in deferred compensation and a bonus. Ignagni won't say how many hours a week she works. The number's so high it's embarrassing, she said.

Among successes cited by Reinhardt and others is helping persuade the Bush administration to develop private insurance plans within Medicare that are producing unexpectedly high payments for private insurers. When Congress was considering expanding a children's health insurance program in 2007 by taking money from the private Medicare Advantage plans, Ignagni worked successfully to stop it. Those private plans are being targeted again by Obama, who wants to squeeze them to pay for his health care agenda. Ignagni's industry group is organizing older people to defend the plans.

There’s lots of more puffery about how she’s good at building consensus among the diverse interests in her group. My take on that is “we’ll see”.

Money-Driven Medicine—N.Y. Premiere of Film, June 11

May 25, 2009• 16

By MAGGIE MAHAR

At last, Money-Driven Medicine is finished. This 90-minute documentary was produced by Alex Gibney, best known for his 2005 film, Enron: The Smartest Guys in the Room and his 2007 Academy Award Winning documentary, Taxi to the Dark Side.The film was directed by Andy Fredericks, and is based on my book, Money-Driven Medicine: The Real Reason Health Care Costs So Much (Harper Collins).The Century Foundation and the New York Society for Ethical Culture are co-hosting the New York premiere on June11, 7p.m. at the New York Society for Ethical Culture, 2 West 64th Street at Central Park West. Doors open at 6:30. Admission is free. If you’re planning to attend, please RSVP Loretta Ahlrich, ********@*cf.org“>ah*****@*cf.org or (212) 452-7722 so that we can have a rough idea of how many people will be coming.

Alex Gibney will be there to talk about the film, and following the screening, I’ll take questions from the audience about healthcare and healthcare reform.

About the Film: Money-Driven Medicine explores how a profit-driven health care system squanders billions of health care dollars, while exposing millions of patients to unnecessary or redundant tests, unproven, sometimes unwanted procedures, and over-priced drugs and devices that, too often, are no better than the less expensive products they have replaced. As I have said on this blog, this isn’t just a waste of money. It’s ‘hazardous waste’—waste that is hazardous to our health.In remarkably candid interviews both doctors and patients tell the riveting, sometimes funny, and often wrenching stories of a system where medicine has become a business. “We are paid to do things to patients,” says one doctor. “We are not paid to talk to them.”Patients,and physicians star in the film. They include Dr. Don Berwick, author of Escape Fire and founder of the Institute for Health Care Improvement , and Dr. Jim Weinstein, Director of Dartmouth’s Institute for Health Policy and Clinical Practice. ( Dr. Jack Wennberg, the founder of what I often refer to as “the Dartmouth Research” passed the torch to Weinstein in 2007.)Lisa Lindell, a HealthBeat reader, patient advocate and author of 108 Days, also appears in the documentary, talking about her husband’s experience in a Texas hospital after he was seriously burned in a freak industrial accident.

How Physicians Inspired Money-Driven Medicine: I narrate the film, and in the course of the narration, recall how the story began:“When I started writing the book, I began phoning doctors, explaining the project, and asking for interviews. To my great surprise the majority of them returned my calls. In most cases, I didn’t know them. I expected responses from perhaps 20 percent. Instead, four out of five called back.“‘We want someone to know what is going on,’ explained one prominent physician in Manhattan. ‘But please don’t use my name. You have to promise me that. In this business, the politics are so rough—it would be the end of my career.’”They were right. Everyone needs to know.

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

Thomas Kuhn, Health Care Reform and Vascular Disease

May 24, 2009• 12

By WILLIAM BESTERMANN

The puzzle of improving care and reducing costs in American medicine and in vascular conditions (that is, diseases associated with blood vessel metabolism) in particular – these are responsible for 60 percent of all cost – has been in part due to the nature of medicine itself. Physicians are at their core scientists. Our undergraduate degrees are in the scientific disciplines of biology, chemistry, physics. We have been educated in the culture of science and that is the environment in which we practice.

Thomas Kuhn’s The Structure of Scientific Revolutions perfectly describes a central problem in cardiovascular diseases. A scientific community cannot practice without a set of core beliefs. These central constructs are, in Kuhn’s terms, the foundation of the “educational initiation that prepares and licenses the student for professional practice.” The student’s instruction is “rigorous and rigid,” with the purpose of ensuring that these beliefs are firmly fixed in the student’s mind.

Scientists go to great lengths to defend the idea that they know what the world is like. It should come as no surprise then that “normal science,” – that is, the framework to explain the world used by the scientists who lead the current paradigm – will often suppress novelties that undermine its foundations.

So research often is not about discovering the unknown, but rather “a strenuous and devoted attempt to force nature into the conceptual boxes supplied by professional education.” A generally-accepted paradigm, essential to effective scientific investigation, requires “some implicit body of intertwined theoretical and methodological belief that permits selection, evaluation and criticism.” That paradigm, in turn, forms the basis of a new profession or specialty, like Interventional Cardiology, and from this follows the establishment of journals, societies, and a special place in the medical academic structure. The articles in those journals are intended for professional colleagues who share the the field’s knowledge and who are the only ones capable of fully understanding them.

A shift in the accepted scientific construct occurs when research aimed at further developing that formulation of the evidence runs into an anomaly — a fact that does not fit the paradigm and cannot be explained away. When anomalies pop up, they typically are not welcome and may be ignored. The current paradigm’s scientists may make little or no effort to formulate a new theory to explain the phenomenon. They are also likely to be intolerant of practitioners who try to do so.

All the same, the discovery of anomaly is the stimulus that leads to a new paradigm. The failure of existing beliefs and rules is the necessary but insufficient platform for the development of new scientific and practice structure.

The leaders of an entrenched paradigm strongly resist alternate systems of science and practice. Only in crisis can that resistance be overcome. No better example of this can be found than the current situation in the treatment of cardiovascular and arterial disease.

*****

The fixed blockage is the dominant paradigm today for both the science and practice of cardiovascular and arterial disease management. In other words, it is viewed as a plumbing problem. This paradigm has persisted because it made so much sense.

Angina is a historical diagnosis – particularly in a man. Just talk to the patient and you can make the diagnosis. If a man walks and gets chest pain that is relieved by rest, he has angina. Almost all of those men have a blockage of 70% or greater.

If the cardiologist does a catheterization he will demonstrate the blockage. If he opens the blockage with a stent the pain will go away. But many men with angina go on to have heart attacks – it is high risk. So it is no surprise that blockage became the dominant scientific paradigm. To this day, virtually the entirety of the science, practice, and financing are organized around this idea: Heart attacks are caused by a progressive blockage. If we open that blockage before it becomes complete, we will save the patient.

Now the anomaly. In 1988, WC Little and his colleagues at Wake Forest performed a study “to help determine if coronary angiography can predict the site of a future coronary occlusion.” If the plumbing model were correct and a progressive blockage of the artery caused myocardial infarction, the findings on coronary angiography should predict the site of heart attack. It did not.

Little and his colleagues studied 42 consecutive patient records of patients who had had coronary angiography before and up to a month after having a heart attack. In 19 of 29 (66%) patients, the artery that occluded subsequently had less than a 50% occlusion on the first angiogram. In 28 of 29 (97%) the stenosis (or narrowing of the vessel) was less than 70%, even though it takes a stenosis of 70% or greater to justify angioplasty with stenting.

Little concluded

“Because it was difficult to predict the site of subsequent occlusion in our patients from the initial coronary angiogram, coronary bypass surgery or angioplasty appropriately directed only at the angiographically significant lesions initially present in almost all of our patients would not have been effective in preventing the majority of infarctions…instead effective therapy to prevent myocardial infarction may need to be directed at the entire coronary tree…”

And, in keeping with Kuhn’s description of the scientific revolution, the best arterial disease scientists quickly developed a new paradigm that provides a much better explanation of the mechanism of heart attack and other vascular events. Within 7 years of the first anomaly, Erling Falk, Prediman K Shah and Valentin Fuster, leading academic cardiologists, summarized four studies that came to the same conclusion as Little. Only 14% of heart attacks occur in an artery that was 70% blocked on the previous catheterization. Only 14% of heart attacks occurred in an artery with enough obstruction to cause angina and justify bypass surgery or stenting. Falk and his colleagues described the new paradigm very simply:

“plaque disruption with superimposed thrombosis (obstructive clot) is the main cause of the acute coronary syndromes of unstable angina, myocardial infarction, and sudden death.”

Peter Libby is Chief of Cardiology at Boston’s Brigham and Women’s Hospital, one of Harvard’s teaching hospitals. One of the world’s foremost authorities on the science of heart attack and plaque rupture, he quite literally “wrote the book” on the topic. In the volume of Harrison’s Principles of Internal Medicine, the standard reference text for the discipline, that sits on my desk, Peter Libby wrote the chapter entitled The Pathogenesis of Atherosclerosis.

In 1995, the same year as the Falk article, Libby wrote a piece called “The Molecular Basis of the Acute Coronary Syndromes.”

“Bypass surgery or transluminal angioplasty (dilation of the artery and then, propping it open with stents) provide rational and often effective therapies for these fixed, high-grade stenoses (blockages). However, these treatments do not address the non-stenotic but vulnerable plaque (which may rupture and suddenly block the artery with clot). It is of interest in this regard that despite the well-accepted benefit of coronary bypass surgery on anginal symptoms, this treatment aimed at severe stenoses does not prevent myocardial infarction. To reduce the risk of acute myocardial infarction, one must stabilize lesions to prevent this disruptions, particularly the less stenotic plaque.”

In other words, heart attack is not caused by a gradual narrowing of the artery, but rather is the result of sudden cholesterol plaque rupture with subsequent clot formation, which blocks off the artery and cuts off blood flow.

Today, 14 years later, we can dramatically stabilize plaque and reduce plaque progression by smoking cessation and reduction of cholesterol, triglycerides, blood pressure, and blood glucose. We can prevent clot formation with aspirin and other medications.

The scientific revolution in vascular disease is 20 years old and the new paradigm firmly in place and supported by the very best vascular scientists. Still, the practice paradigm persists as if the science never changed.

Just last year, I heard a brilliant talk by Valentin Fuster, one of the co-authors on the Falk article. Afterward I asked him what it would take to move the practice paradigm forward. He responded that it would take the time required to replace current practitioners wi
th the next generation.

Can we afford to wait for that? Several years ago, I heard Dr Libby speak at a national meeting of the American Society of Hypertension. I later asked him, “Dr Libby, I read your article from 1995, saying that bypass and stenting do not prevent heart attack, do you still hold that view.” He became very animated and enthusiastic and said he was convinced that the new science was valid and required action to move it forward.

The science has become irrefutable. Yet the defenders of the old science still carry the day. I fear that medical scientists will not move this forward and it will require changes in payment and support for research coming from outside the professional community to bring the latest science to patients.

We have to recognize the suppression of anomalies and new paradigms in medicine. Only then can we develop mechanisms that can bring the latest evidence-based science to patients.

Bill Bestermann is Medical Director, Integrated Health Services at Holston Medical Group in Kingsport, TN.