Why I Support Health Care Reform

One advantage of blogging is that I can share my ideas, directly, with people who find them interesting, provocative or otherwise read-worthy. So for those who are curious, here is my general view on health care reform (HCR) by any name, in 3 points:

First, we need it. The U.S. health care system doesn’t work. It doesn’t serve doctors. Good physicians are few and far between in some geographical regions, in primary care and in needed specialties (like oncology and geriatrics). It doesn’t serve people who might be patients, except if they happen to work for a generous employer that offers a good plan (few do), they are rich enough so they might spend thousands each year out-of-pocket and out-of-network, or they are most fortunate of all, having no serious medical problems to contend with or pay for.

Second, although I wholeheartedly support the Affordable Care Act, because it’s a step in the right direction, I don’t think the legislation goes far enough. We need a simpler, single-payer solution, as in a national health care program, Medicare-style, for all. Why? Because the quasi-plan for state-based exchanges, each with competing offerings and not necessarily interpretable terms of coverage, is too complicated. There’s no reason to think a free market operating at the state level would match the public’s or many individuals’ medical needs. As long as each provider is trying to make a buck, or a billion, it won’t put patients’ access to good care first. Besides, there’ll be administrative costs embedded in each exchange that we could live better without. As for private insurers, well, I couldn’t care less about the well-being of those companies or their executives’ incomes.

Profit is not what medical care is about, or should be about. What we need is a simple, national health plan, Europe-style, available to everyone, with minimal paperwork and, yes, limits to care.

Third point – on rationing.

Some of my readers may wonder how I, who support some costly components of good medical care, like providing breast cancer screening for middle-aged women and sometimes giving expensive drugs to people with illness, favor health care reform. New cancer meds cost around $100,000 year, more or less, as do innovative treatments for cystic fibrosis, inflammatory bowel disease, rheumatoid arthritis and other conditions. I don’t think the sane solution is abandoning expensive but life-saving and quality-of-life-improving treatments.

The hardest part of this debate and what’s so rarely discussed is the appropriate limits of medical treatment, not based on costs – which we can certainly afford if we pull back on administrative expenses of health care and insurers’ huge profits – but on factors like prognosis and age. So, for example, maybe a 45 year old man should get a liver transplant ahead of an 80 year old man. Screening for breast cancer, if it is valuable as I think it is, should perhaps be limited to younger women, maybe those less than 70 or 75, based on the potential for life-years saved. Maybe we shouldn’t assign ICU beds to individuals who are over 85, or 95, or 100 years old.

The real issue in HCR, if you ask me, is who would decide on these kinds of questions. That conversation’s barely begun, and I would like to participate in that…

Meanwhile, the Supreme Court is busy doing its thing, sorting out whether the Affordable Care Act is constitutional or not. I’m glad they’re on the case, so that they might find that it stands and we can move on and forward.

#Obamacare is right –

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What Does it Mean if Primary Care Doctors Get the Answers Wrong About Screening Stats?

Last week the Annals of Internal Medicine published a new report on how doctors (don’t) understand cancer screening stats. This unusual paper reveals that some primary care physicians – a majority of those who completed a survey – don’t really get the numbers on cancer incidence, 5-year survival and mortality.

An accompanying editorial by Dr. Virginia Moyer, a Professor of Pediatrics and current Chair of the USPSTF, drives two messages in her title, What We Don’t Know Can Hurt Our Patients: Physician Innumeracy and Overuse of Screening Tests. Dr. Moyer is right, to a point. Because if doctors who counsel patients on screening don’t know what they’re speaking of, they may provide misinformation and cause harm. But she overstates the study’s implications by emphasizing the “overuse of screening tests.”

The report shows, plainly and painfully, that too many doctors are confused and even ignorant of some statistical concepts. Nothing more, nothing less. The new findings have no bearing on whether or not cancer screening is cost-effective or life-saving.

What the study does suggest is that med school math requirements should be upped and rigorous, counter to the trend. And that we should do a better job educating students and reminding doctors about relevant concepts including lead-time bias, overdiagnosis and – as highlighted in two valuable blogs just yesterday, NPR Shots and Reporting on Health Antidote – the Number Needed to Treat, or NNT.

The Annals paper has yielded at least two unfortunate outcomes. One, which there’s no way to get around, is the clear admission of doctors’ confusion. In the long term, this may be a good thing, like admitting a medical error and then having QA improve as a consequence. But meanwhile some doctors at their office desks and lecterns don’t realize what they don’t know, and there’s no clear remedy in sight.

Dr. Moyer, in her editorial, writes that medical journal editors should carefully monitor reports to ensure that results aren’t likely misinterpreted. She says, in just one half-sentence, that medical educators should improve teaching on this topic. And then she directs the task of stats-ed to media and journalists, who, she advises, might follow the lead of the “watchdog” HealthNewsReview. I don’t see that as a solution, although I agree that journalists should know as much as possible about statistics and limits of data about which they report.

The main problem elucidated in this article is a failure in medical education. The cat’s out of the bag now. The WSJ Heath Blog covered the story. Most doctors are baffled, says Fox News. On its home page, the Dartmouth Institute for Health Policy & Clinical Practice links to a Reuters article that’s landed on the NIH/NLM-sponsored MedlinePlus (accessed 3/15/12). This embarrassment  further compromises individuals’ confidence in doctors they would and sometimes need rely on.

We lie, we cheat, we steal, we are confused… What else can doctors do wrong?

The second, and I think unnecessary, problematic outcome of this report is that it’s been used to argue against cancer screening. In the editorial Dr. Moyer indulges an ill-supported statement:

…several analyses have demonstrated that the vast majority of women with screen-detected breast cancer have not had their lives saved by screening, but rather have been diagnosed early with no change in outcome or have been overdiagnosed.

The problem of overdiagnosis, which comes up a lot in the paper, is over-emphasized, at least as it relates to breast cancer, colon cancer and some other tumors. I  have never seen a case of vanishing invasive breast cancer. In younger women, low-grade invasive tumors are relatively rare. So overdiagnosis isn’t applicable in BC, at least for women who are not elderly.

In the second paragraph Dr. Moyer outlines, in an unusual mode for the Annals, a cabal-like screening lobby:

 …powerful nonmedical forces may also lead to enthusiasm for screening, including financial interests from companies that make tests or testing equipment or sell products to treat the conditions diagnosed and more subtle financial pressures from the clinicians whose daily work is to diagnose or treat a condition. If fewer people are diagnosed with a disease, advocacy groups stand to lose contributions and academics who study the disease may lose funding. Politicians may wish to appear responsive to powerful special interests…

While she may be right, that there are some influential and self-serving interests and corporations who push aggressively, and maybe too aggressively for cancer screening, it may also be that some forms of cancer screening are indeed life-saving tools that should be valued by our society. I think, also, that she goes too far in insinuating that major advocacy groups push for screening because they stand to lose funding.

I’ve met many cancer agency workers, some founders, some full-time, paid and volunteer helpers – with varied priorities and goals – and I honestly believe that each and every one of those individuals hopes that the problem of cancer killing so many non-elderly individuals in our society will go away. It’s beyond reason to suggest there’s a hidden agenda at any of the major cancer agencies to “keep cancer going.” There are plenty of other worthy causes to which they might give their time and other resources, like education, to name one.

Which leads me back to the original paper, on doctors’ limited knowledge –

As I read the original paper the first time, I considered what would happen if you tested 412 practicing primary care physicians about hepatitis C screening, strains, and whether or not there’s a benefit to early detection and treatment of that common and sometimes pathologic virus, or about the use of aspirin in adults with high blood pressure and other risk factors for heart disease, or about the risks and benefits of drugs that lower cholesterol.

It seems highly unlikely that physicians’ uncertainty is limited to conceptual aspects of cancer screening stats. Knowing that, you’d have to wonder why the authors did this research, and why the editorial pushes so hard the message of over-screening.

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Harsh Words, and Women’s Health at Risk

I’ll open with a confession –

Women’s health has never really been at the heart of ML. Your author has, historically, relegated subjects like normal menstruation, healthy pregnancy and reproduction and natural menopause to her gynecologist friends. Sure, I learned about the facts of life. I even studied them in med school and answered questions, some correctly, along the way. By now, I’ve lived through these real life-phases directly. But these topics never drew me. That’s changed now.

Women’s care – and lives, in effect – are jeopardized on three fronts:

First, on birth control. Last week the Senate narrowly tabled a move to limit insurers’ responsibility to cover contraception. The vote on the so-called “conscience” amendment was 51-48. What this tells us is that essentially half of that powerful group either agrees with limiting women’s access to birth control or sees it as dispensable in the context of political aims.

The very fact that the proposal reached the Senate floor is disturbing. Without access to birth control, women –  including teenagers, people with significant medical problems that can be exacerbated by pregnancy, those who can’t afford to feed another child, and some who are already troubled or otherwise might not be ready or prepared to have children – are much more likely to become pregnant. It shouldn’t take a doctor to articulate this obvious point, and I can’t understand why so many are silent on it, but since so few physicians and the AMA in particular hasn’t issued any statement on this, I’ll stick my neck out and say it clearly: Lack of contraception puts women and their conceivable future-kids at risk for health problems that could be avoided.

The language surrounding the amendment is problematic, besides. Who are the anti-birth control legislation-writers to imply that “conscience” is involved in withholding contraception, and not the other way around? It’s like the “pro-lifers” who’ve implied that the rest of us aren’t.

Second, on access to safe abortions. I respect that some people think it’s wrong to terminate a pregnancy. But I also know that plenty of women, especially young women, get pregnant who don’t want to be pregnant. Regardless of who’s “responsible” – and any reader of this blog knows I’m no sucker for finger-pointing and behavior blame games – the bottom line is that if abortions become out-of-reach, women will suffer hemorrhage, life-threatening infections, permanent infertility  and premature deaths.

Hard to know how many women had ill effects or died from botched abortions before January, 1973, when the Supreme Court issued its decision on Roe vs. Wade. Like most women of my generation, I know of those unfortunate outcomes only indirectly. Still, I can’t rid my brain of the scary, unclean place Natalie Wood visits with a wad of cash in the 1963 movie Love with the Proper Stranger, or the tragic outcome when actor Gael García Bernal takes his pregnant love to an abortionist in the film Crime of Padre Amaro, set a decade or so ago in Mexico. But the real scoop comes from older physicians and nurses, here and now. When I was in med school in the 1980s, they told me stories of women and girls showing up in the emergency room bleeding, pale… dead.

As outlined by editorialists and writers elsewhere, mergers of Catholic hospitals with other medical centers threaten to reduce or eliminate access to abortions in some rural areas. In states like Texas, the physical and emotional rigmarole to which pregnant women are subjected prior to an abortion – including mandatory listening to a description of the fetal organs and a discussion loaded make what might be a tough decision unbearable, especially if the woman lacks confidence.

Which leads me to the third point of vulnerability – that women should be able to obtain care without intimidation or emotional abuse.

When Rush Limbaugh spoke last week, he wasn’t just talking about one Georgetown Law student. He was speaking to and about millions of young women who are sexually active. He called them sluts and insinuated they are like prostitutes. Adding insult to verbal injury, he said he’d like to watch videos of the sex. You could say who cares, he’s just some right-winged showman blowing off steam and misogyny. But this is a man who speaks to conservative leaders and feeds ideas to many households in America. Scary that the Republican front-runners, men who would be President of the United States next year, didn’t call Rushbo out. Rather, they let it go. As they might your daughter’s health, or access to birth control, or to a safe abortion.

In this new climate of shame, it’s easy to imagine a girl in some communities might feel really, really bad about herself simply for being sexually active. Whether she’s 17 years in high school, or 21 years in college, or 25 and maybe a department store clerk – and possibly lonely or confused – she may be embarrassed to ask for birth control. The Scarlet C, Robert Walker aptly called it yesterday.

The paradox is that this kind of rough talk, posturing and in some states, puritanical law-making, make it more likely that a sexually active young woman will become pregnant. And if she does become so, now, she may delay seeing a doctor because she fears his or her moral judgment about her behavior. And that leads to less healthy outcomes, and more deaths – fetal and maternal.

This is a serious health issue. I wish more doctors would speak out about it.


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