Posting in Government
The only way we will ever cut health costs is by making hard choices on what we should be covering. Our present system puts politicians in charge of this. Comparative effectiveness gives data a chance.
It doesn't matter. This battle was lost before it started.
The battle was lost in January, during the debate over what is now known as "the stimulus." A big hunk of that money, $19.2 billion, was to be spent automating doctors' offices and hospitals. This would save money, we were told.
How? It would let scientists access the country's entire health record for the first time. Instead of just looking at data from, say, the Framingham Heart Study, they would have health records from all 300 million of us.
With all that data we could finally know, definitively, what works and what doesn't. Strip the names out, strip out the addresses, phone numbers, every possible identifier, and that firehose of data would finally let us know what we should be paying for, and what we shouldn't be paying for.
The statistical science I described above is called comparative effectiveness. Remember what anti-reform zealot Betsy McCaughey (above) called this in January? "Getting between you and your doctor."
The charge that "government bureaucrats" would decide "who would live and who would die" forced the Administration to backtrack, and say that while we'll collect the data, we won't use it to make decisions.
This effectively killed health reform.
Health reform has always been based on two goals -- "bending the cost curve" and "covering everyone." Comparative effectiveness would let us meet that first goal.
Without it, we have a political process. That's what is crazy about the Stupak Amendment nonsense. Not the abortion, but the fact that politicians were deciding what should be covered, based on political considerations.
That's what we have now.
States regulate insurance companies, which means state governments now decide what will be covered and what won't. It's an inherently political process. Do Christian Scientists have good lobbyists? Do chiropractors? You're out or you're in based, not on science, but on the political arguments you make and the political efforts you make on their behalf.
The only way we will ever cut the rate of health care inflation, let alone cut costs, is by making hard decisions on what we should be covering, through insurance or government, and what we shouldn't be covered. You can still get services that don't work -- just don't make me pay for them.
Our present system puts politicians in charge of this. Comparative effectiveness gives data a chance.
But we won't have comparative effectiveness. We decided that in January. So it doesn't really matter all that much whether Congress passes health reform.
The battle has already been lost.
Nov 13, 2009
After yesterday's Senate vote on the Mikulski amendment, I guess comparatve effectiveness is dead. Why do politicians think they are somehow less meddlesome than "bureaucrats" that at least try to reach decision based on some kind of logic.
Almost every statement made in Washington to support national healthcare is the opposite of the truth. It will drive up premiums, it will give us less choices and it will cause quality to go down, and competition will be eliminated because the private sector will be pushed out and the states will be overrun. Some states are doing better than others with healthcare but that doesn't mean the federal government will be able to do better. Do the lower premium states have a better model or do the ones with more services have the better model? If pubic health insurance is such a good idea, why do California and Massachussets have trouble affording it? If they can't then how will it be magically affordable for the entire country? The federal government should leave this entire issue to the states. Each state has its own responsibilty to determine what is best for its own residents. No state is too big to fail.
This is a bit irrelevant to the discussion of comparative effectiveness, but insurance is presently regulated exclusively by states. States decide what must be covered -- AIDS, maternity, moles, etc. -- and science doesn't enter into it. You're right that most state insurance markets are virtual monopolies or (at best) oligopolies in which a very few companies dominate the market. That's what all this bit about "ending the anti-trust" exemption is about. Right now, the federal government has no role in health care, under the 1946 McCarran-Ferguson Act. http://en.wikipedia.org/wiki/McCarran%E2%80%93Ferguson_Act. At least one proposal before Congress would assert a federal role in health insurance regulation, ending the current exemption from federal regulation. That's also where some of the talk of the 10th Amendment comes from. This is presently a state, not a federal matter. But if you want nationwide standards of torts, and interstate competition among insurers -- as conservatives claim they want -- then you have to federalize insurance regulation.
Your argument conveniently skips over the preamble to the entire document. http://en.wikipedia.org/wiki/Preamble_to_the_United_States_Constitution This is not a "when in the course of human events' preamble. This is substantive stuff. (Ahem.) We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America. Notice insure domestic Tranquility and promote the general Welfare. If your argument had any merit it would have been addressed by courts when Medicare was passed in 1965. You want the Supreme Court to declare Medicare unconstitutional? Maybe you can make an argument with this court. But it would result in a switch in time to save the nine. So it ain't happening. The current health reform proposal is no more intrusive than Medicare. Less.
You're right. But base the arguments on data. Comparative effectiveness is about collecting the data. Let the arguments be about data and they will have to be better than arguments made solely by lawyers, spinning words.
A more logical National Health Care System is laid out in the book "True Freedom - The Road to the First Real Democracy". Until the taxpayers wake up to the real world and the governments at the same time fix the waste in the systems which exist today no one will win and in the end the nation itself will fail. Oh, by the way, I found the book on the site www.democraticroad.com if you are interested.
@stano360... Yes, I blame the Republicans. And the Democrats. I blame all the spineless wretches we have put into office over the last thirty-odd years for the state this nation is in. I blame them for acceding to the insane melody fostered on us by the Reagan administration, what the first President Bush called "voodoo economics." I blame them for wasting the intervening years since the first OPEC oil embargoes of the early seventies as we've gotten even deeper into an addiction to foreign oil and foreign capital to finance our profligate lifestyle. I blame them for lying about things like WMDs and the real threats to this nation. I blame them for placing party above country, and ideology above fact, and for putting forth candidates of the caliber of some that we've seen recently for high offices in this land. I blame them for not being patriots first, but demagogues and rabble-rousers, more interested in fanning the flames of ignorant passion than having a debate to really look at the facts and honestly held (and informed) viewpoints. So, yeah, I blame the Republicans. They're the most visible example of a plague that's sweeping this country, putting us in a place the likes of which I haven't seen in almost sixty years. There's nothing "grand" about the GOP, but there sure is a lot that's "old" about it. The party of Lincoln is living in a self-imposed bubble of self-deception and delusion, and its legacy deserves better. And to all those name-callers out there who brand this or that as "socialist," one question--do you _really_ know what you're talking about? Most of what you brand as "socialist" was seen as a social good when they were first put into effect. Read your high school civics books. There seem to be large parts of this country's history of which you're totally ignorant. Enough shouting. Enough screaming. And enough name-calling. I've got it out of my system. Can we just sit down and talk now, understanding that we're all at fault, and we all have to make this one lifetime work and mean something? Is it too hard for us to think of "one nation, under God, with liberty and justice for all"?
'You' didn't lose. But 'we' probably will. Having lived for years in the Utopia you describe, I finally came to my senses, and returned to reclaim my birthright. I'll be damned (literally) if I let leftists take it from me, and destroy the last bastion of freedom on this planet. If you want your socialist dream so badly, then just do what I did, and go join them. It's already out there waiting for you, and a lot of them, like the entire UK, South Africa, and much of India, even speak English. It wouldn't be that much of a transition for you. So, go. And leave us alone. If you and your ilk keep insisting on bringing it here, you'll only succeed in rending this country. But maybe that's just what you want.
The statistical science I described above is called comparative effectiveness. Remember what anti-reform zealot Betsy McCaughey (above) called this in January? ?Getting between you and your doctor.? We need to get between the drug industry and their obscene profits.
A few points. 1. Comparative effectiveness is a concept that came from the insurance companies. They want it to replace the HMO concept with something legally defensible. 2. Every country that has lower health care costs than we do, and better outcomes, is relying on massive piles of data to driver best practices and relevant formularies. 3. Those who claim politics is inevitable as the basis of decision making are practicing politics. I think what we need most is a constituency demanding good science, including the use of statistics, so we pay first for what works, not for unproven stuff like Christian Scientists praying over us.
I'm convinced that, sooner or later, we'll have reform, not as a part of any political process to correct a health-care system that's out of control, when it isn't, but as a direct result of market forces. Mind, I'm not a fan of free market, but our health-care system is a natural outcome of that process, where supply (very limited) and demand (as high as life itself, literally), raise prices beyond the reach of all but the most wealthy. The only way to provide health coverage under such a free market system is to allow non-physicians to provide some lesser care coverage. I don't like, but there's the dirty truth.
"Comparative effectiveness" didn't have a relevant constituency in Congress or the White House. I don't even think they want that kind of accurate data, because data that everyone takes seriously would only get in the way of politics. Not that it would have mattered that much. Access to hard data has never stopped politicians from doing what they ultimately want to do anyway, so why should we have expected having access to compiled data everyone's health data for the sake of making policy to make any difference? It would have been useful on many levels, like in pharma R&D. But in the polarized world of Washington, it would be just something else to fight about. The real problem was indulging any expectation that Congress was capable of "making hard decisions on what we should be covering, through insurance or government, and what we shouldn?t be covered." For example, they couldn't even let the recent lack of a COLA adjustment in Social Security go by without voting to go ahead, override existing law and send out a few more billion anyway, lest the seniors get more pissed off. Everyone knows that whatever bill eventually gets passed, almost immediately they will start tweaking and amending it to add back all the special interest gunk that was pulled to get it passed the first time around. Politicians will be politicians, and it's daft to expect more out of them just because they have better data.
Sorry folks, but I don't believe for a minute that our beloved Federal government should be in charge of health care - just look at how poorly and inefficiently and at what great cost things are done at the national level! Never mind the constitutionality of it all. The Dems have no one to blame but themselves for this mess. If they were truly wanting health reform, they could have easily tackled key pieces, one at a time - things like Medicare fraud, defensive medicine, tort reform, comparative effectiveness, drug costs, standardized electronic records, etc. Instead, they give us a bloated, costly piece of legislation with all sorts of non-healthcare bones for their constituents (take abortion for instance). The current competing bills make it nigh impossible to have a real debate and prevent the individual components from truly being debated on their merits. Typical Washington at its best..
there have been whole societies in which the big lie was always taken as the truth. some of those societies existed in my lifetime, and the present u.s. is run partially this way. it is not enough to be against something for rational reasons, but one must then lie lie lie to swing the population, usually ignorant of reality and lately frightened to death, his way. in recent years, the right has been far more adept at it than the left, though that is only in recent years. the left had their heyday in the 1930s and 1940s. we live in a politically run country, as it was set up to be and as it should be. unfortunately the founders were expecting far better representatives in the congress than we have.i am sure they thought that elected officials would recognize their higher calling, instead we have a picked group made up by a large number of bottom feeders whose only calling is to keep living off the government's tit, both at the state and federal level. one looks and only sees a bunch of losers, who will spend trillions on war, unnecessary war, that kills our young people and will spend nothing on the saving of large numbers of the citizens' lives. worse is that they go off every sabbath and pray and immediately forget the basic teachings of their faiths; their personal responsibility to their fellow man. worse are the people like someone who signed in as repeal, who in trying to teach all of us what the constitution means has only shown that he does not understand it at all.
We may not get full-blown, official and comprehensive comparative effectiveness capabilities, but there may be some approximations that may still enable progress to be made. NPR has a story today about Patients Turn To Online Community For Help Healing, based on a recent report on The Social Life of Health Information by Susanna Fox of the Pew Internet and American Life Project. I'll include a few excerpts below. "They are posting their first-person accounts of treatments and side effects from medications," says Fox. "They are recording and posting those podcasts. They're tagging content. They are part of the conversation. And that, I think, is an indicator of where we could be going in terms of the future of participatory medicine." ... Jamie Heywood, who created another site called Patients Like Me, says people are used to tracking all kinds of personal information online. So they don't understand why they can't get the records that their own doctors can order up. "What's sad is, you know, they order all this information, and they get it back from the lab, and it comes back in this rich electronic format with all this information on it," he says. ... "The amazing shift is that we've pushed out this concept of sharing," says Heywood. "Which is to say: If you share information about your own experience with this disease, then we can facilitate the conversation that you want to have with the person in the world who is just like you ? whether they live in Vancouver, Canada or Australia, or down the block." You can find another patient who knows what you're going through, says Heywood, someone who "is on the same treatments, is dealing with the same side effects ... whatever variable matters to you at that moment. To find out whether your concerns are justified, they make sense, whether you're doing the right thing ? that's the transformation."
Uh, last time I check the Democrats can put any bill they want through Congress, Senate and get a signature in the White House without a Republican vote. Ironically many of the problems listed in the article are caused by government not insurance companies. Why am I forced to buy insurance that has maternity coverage, drug counseling, mental health coverage or AIDS coverage when I will never use any of those? Why when I shop for insurance are there only 5 companies (4 if you don't count Kaiser, effectively the private "public option") to choose from? Government regulations that's why.
Dana-- I saw an article in the NY Times this morning about the drug companies raising the prices on their medicines in anticipation of some sort of "health-reform" legislation. That way, when the bill was passed, whatever it might be, they could point to higher base pricing, so they would see less profit erosion as target pricing was negotiated. This is one more example of the ability that the major players in our health care system have to game that system and make it turn to their advantage. We've already seen the demise of a real public option, as we're now talking about an opt-out state-by-state system. We'll undoubtedly see more of the same, as other major powers get their pounds of flesh. I've become completely cynical about the possibility of this administration and this congress being able to do anything positive in the health care arena. The Republicans have managed to work a relatively weak position to their own ends by endless misleading rhetoric, loony-tunes misdirection, and flat-out lying to the public. The Democrats in many ways are no better, caving to the siren song of the chorus of lobbyists that are at work in Washington. I believed a year ago there was some chance of real "change we can believe in" taking place in our national government. I'm no longer so naive. Even with a bunch of new players, and with high-minded rhetoric, the old forces of stall, delay, and kill are still in power in the capital of our nation. A pox on all of them, and a double dose on those who align with the GOP. This country will continue its decline as long as these clowns are steering the car.
It boils down to who is the patient and who is the doctor and who is paying for it. If someone walks in with a mole and says 'remove it' but the comparative effectiveness have shown that removing moles provide no medical benefit to 95% of the people it results in that one is allowed to remove moles anymore that puts statistics in charge - not the doctor nor the patient. What the patient wants is now irrevelant and it is all about statistics. And once PROVEN it will not be studied again - since no more moles are allowed to be removed it fulfills the goal that removing them does not benfit the person medically. As to who pays for all this - since 70% of the people fall (as currently envisoned) into the low income zone where credits / subsidies cover their full benefits with no payments that leaves 30% of the working popluation to pay for their own and the other 70% of the people who are going to get it free. (medium income around 60,000 for a four person family with two working in 2006). and the poverty level is set at 22,000 for 2009 and the bill has it set for 2.5 times poverty level (? last I saw) or around 53,000. Since most kids are born to people when their income is low almost every family would get all medical free and after kids are gone then they start paying taxes to pay for their own and for all the new kids coming. When someone retires their income drops and so they also effectively drop out of paying lots of taxes. thus it falls to people between 45 and 65 to pay for ALL the medical cost of everyone else in the USA. To make it pay that means if someone / family makes more than 120,000 at least 5,000 additional has to be used just to pay for medical taxes in order for the balance sheet to work in covering everyone - above the $25,000 already being paid in taxes for normal tax year and since we are a progressive taxing method it has to slide up so that people earning above 250,000 has to pay at least an additional $25,000 a year. Else addtiional taxes needed to cover everyone fails to collect enough.
Welcome to America. Providing Health Care is not a role of the Federal Government. That role is reserved to the States and the people. The enumerated powers are a list of specific responsibilities found in Article 1 Section 8 of the United States Constitution, which iterates the authority granted to the United States Congress. Congress may exercise only those powers that are granted to it by the Constitution, limited by the Bill of Rights and the other protections found in the Constitutional text. The 10th Amendment: "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people." Providing and receiving health care does not inherently involve interstate commerce. The reality is families and businesses are not allowed to buy health insurance across state lines. Just like prohibition, Federal Universal Health Care should legally begin with an amendment to the Constitution! And Congress does not have the Constitutional authority to require citizens to spend after tax dollars to purchase any good or service. The Congressional Budget Office studied the issue and discovered that the federal government had never in the history of the United States mandated that individuals purchase any good or service. What would be the definition of disposable income if they could?
The form of Healthcare Reform we're likely to see will be far more expensive, and place far more roadblocks to efficient deployment that we'll be worse off than we are now. Previous studies have shown that it would be less expensive by implementing an across-the-board proactive, preventive medicine program for all citizens that would practically eliminate the use of Emergency Rooms as the means of providing care to the uninsured. Unfortunately, nobody in Congress have read any of those reports (save maybe Ron Paul), certainly not the people on the House or Senate committees; and even if they did, they're not writing the law to improve health care, they're writing the law to improve the bottom line for the healthcare industry, not the patients. As for evolving technology, the evidence is always clear cut; it's the research design and the interpretation of results that are biased by the various members of the healthcare industry that is the problem. Nobody effectively funds research anymore without expecting a financial gain. Editing out the biases, and eliminating the erroneous study methodology are the hard parts. What we have after that is a push toward evdence-based medicine. Don't do it unless there's proof it actually works. If there isn't an effective difference in results for different treatments, use the least expensive.
I agree this is somewhat of a set back but not the end. This comparative process is bound to be part of the debate the future. We have universal health care here in Canada. It is not perfect but not as imperfect as the old system that let people die for lack of money. What the US has now is kind of like letting your dog die of starvation in a recession. You are among the richest countries in the world and you need this. It will add more humanity to your culture and you do need that. Medicare in Canada is one of the aspects that make it as a country even better to live in than the United States! Do not lose this opportunity over trivialities. They can and will be resolved with future debate. In a democracy debate does continue but you do need this passed. It is good for all Americans rich and poor. Medicare may one day save your life!
Dana, Even if we embraced 'comparative effectiveness' there would be arguments and controversies. Technology is always evolving, new drugs, even new diseases, and the evidence is rarely clear cut. Whenever the Gov't makes the decisions politics will be paramount. Which drug or device company gives money to which politicians? The trial lawyers have already mastered that end-around of our system. It is the way our system works. Expectations that some new 'scientific' process will solve our problems are naive.
The only way you can afford to bring everyone into the system is if you change the incentives based on science. Otherwise you make political choices. The only positive spin I can possibly see is that adding more people to the system will force government and insurers to use comparative effectiveness since at least they'll have the data. But that's not the same as saying it makes a whole lot of difference whether a bill without cost controls is better than no cost controls.
I lost you. Because the government says that they won't use comparative effectiveness to make decisions, all of health care reform is lost? I don't think so. I agree with much of what you say, but don't jump to the same conclusion. There are times when political debate bends reality. And there are times when reality prevails in spite of political rhetoric. As long as the comparative effectiveness research effort moves forward there is the very real possibility that research will trump rhetoric. In the meantime we need to get everyone into the system. What good is knowledge about effectiveness to people who can't get inside the system. http://thehealthcaremaze.us