Health Care Reform Articles - May 15, 2014

Should health care be rationed? It already is

By Philip Caper, Special to the BDN

Posted May 15, 2014, at 11:21 a.m.

Opponents of universal health care often claim that in order to afford it we will have to ration health care. My response to that old shibboleth is that we already pay more than enough to cover everybody, and that we already ration health care, as we must in a world of finite financial and real resources. The real question is not, “Should we ration health care?” but rather, “What’s the fairest way to do it?”

In all other wealthy countries, where everybody has a right to health care, rationing is done on the basis of medical need. The more urgent the need, the sooner care is provided. Urgent care is provided promptly, and less urgent care may be put off for awhile.

In many cases, delaying care is actually a good thing. There is a growing recognition that in the U.S. some types of care are too accessible, resulting in costly and risky overuse of many tests and treatments that have little or no value, and others that may actually do more harm than good.

In exchange for restricting access to some tests or treatments of little or no value, we could reduce overall health care costs significantly and largely eliminate cost as a factor in deciding who receives medical care and what kind of care they receive. In most other wealthy countries, the ability to pay does not enter into the thinking of either the patient or the doctor.

The U.S. is unique among wealthy countries in using ability to pay as a means of rationing medical care. The results are often devastating. A recent Commonwealth Fund study found that in states where the number of uninsured is highest, rates of deaths from treatable illnesses are also highest. Another recent study in Massachusetts concluded that morbidity and mortality from treatable illness declined significantly after 2006, when health care reform expanded coverage there.

I’m in favor of expanding health care coverage to everybody and rationing through overall budgetary constraints rather than simply pricing some people out of the system. While some with good coverage receive too much medical care, others without coverage receive too little and may wait forever for needed care.

People who face financial barriers to accessing health care often put off beneficial primary care, only to later require care for more serious and expensive illness. Those costs end up being paid by all the rest of us.

Medical tests, procedures and treatments have their benefits, but they also have their downsides. Drugs have side effects, tests and procedures have risks, and all have economic costs. If we agree to limit access to ineffective, marginally effective or downright harmful care, we could more than afford to expand access to everybody.

In many instances, our aggressive, anything-goes style of medicine has caused more harm than good. Mammography and PSA tests for prostate cancer are recent examples. Over 65 medical specialty societies have each recently identified at least five such tests or procedures.

According to a recent study by the Institute of Medicine, we waste over $340 billion a year on unnecessary and inefficiently delivered services. That’s more than enough to extend coverage to everybody.

I believe most Americans would willingly give up something they may want but don’t really, urgently need if it meant a neighbor who needed it more could have it instead. I’ve seen that happen many times here in Maine. But we seem to have a lot of trouble turning our generous neighborly spirit into public policy.

So why don’t we make our means-tested system of rationing more rational, and, like other wealthy countries, base it on medical need rather than financial means? Not only would our health care system become less costly and more efficient as a result, but it would also become more humane.

Such a change would allow doctors to treat patients the way our training and professional ethics encourage and our Hippocratic Oath demands.

And it would make our country yet a better place to live.

http://bangordailynews.com/2014/05/15/health/should-health-care-be-rationed-it-already-is/print/

It’s Now the Canadian Dream

MAY 14, 2014

It was in 1931 that the historian James Truslow Adams coined the phrase “the American dream.”

The American dream is not just a yearning for affluence, Adams said, but also for the chance to overcome barriers and social class, to become the best that we can be. Adams acknowledged that the United States didn’t fully live up to that ideal, but he argued that America came closer than anywhere else.

Adams was right at the time, and for decades. When my father, an eastern European refugee, reached France after World War II, he was determined to continue to the United States because it was less class bound, more meritocratic and offered more opportunity.

Yet today the American dream has derailed, partly because of growing inequality. Or maybe the American dream has just swapped citizenship, for now it is more likely to be found in Canada or Europe — and a central issue in this year’s political campaigns should be how to repatriate it.

A report last month in The Times by David Leonhardt and Kevin Quealy noted that the American middle class is no longer the richest in the world, with Canada apparently pulling ahead in median after-tax income. Other countries in Europe are poised to overtake us as well.

In fact, the discrepancy is arguably even greater. Canadians receive essentially free health care, while Americans pay for part of their health care costs with after-tax dollars. Meanwhile, the American worker toils, on average, 4.6 percent more hours than a Canadian worker, 21 percent more hours than a French worker and an astonishing 28 percent more hours than a German worker, according to data from the Organization for Economic Cooperation and Development.

Canadians and Europeans also live longer, on average, than Americans do. Their children are less likely to die than ours. American women are twice as likely to die as a result of pregnancy or childbirth as Canadian women. And, while our universities are still the best in the world, children in other industrialized countries, on average, get a better education than ours. Most sobering of all: A recent O.E.C.D. report found that for people aged 16 to 24, Americans ranked last among rich countries in numeracy and technological proficiency.

Economic mobility is tricky to measure, but several studies show that a child born in the bottom 20 percent economically is less likely to rise to the top in America than in Europe. A Danish child is twice as likely to rise as an American child.

When our futures are determined to a significant extent at birth, we’ve reverted to the feudalism that our ancestors fled.

http://www.nytimes.com/2014/05/15/opinion/kristof-its-now-the-canadian-dream.html?hp&rref=opinion

Why Obamacare can't lower costs

By Kip Sullivan, J.D.
Truthdig, May 9, 2014
President Obama and the Democratic Party dug themselves into a deep hole by claiming the Affordable Care Act would cut the nation’s health care costs when in fact it will raise them. It’s the gift that will keep on giving to opponents of the law.
The ACA cannot cut costs because its proponents subscribed to the wrong diagnosis of the U.S. health care crisis. They accepted the conventional wisdom that overuse of health care services is the most important reason why per capita health care costs are double those of the rest of the industrialized world, and that overuse is caused by two chronic failings among American doctors: They routinely order services patients do not need and fail to provide them with obviously beneficial preventive ones that would keep them healthy and minimize later need for medical interventions.
This diagnosis is wrong. First, underuse is far more common than overuse, even among the insured. To cite one example, 80 percent of insured Americans showing telltale symptoms, such as shortness of breath, do not see a doctor. Second, preventive services usually raise spending because they cost more to supply than they save.
Predictably enough, the mistaken “overuse” diagnosis led ACA proponents to the wrong solution, namely, that doctors can be forced or induced to stop ordering unnecessary services and provide more preventive services if they are subjected to more control by insurance companies. But the premises upon which this solution is based are also false. It is not true that the methods that the insurance industry uses to control doctors are so precise that they reduce overuse without aggravating underuse. It is also not true that the insurance industry’s methods are so inexpensive compared with the savings due to reduced overuse that, on balance, costs go down.
The ACA’s failure to control costs might not have mattered if we were still in the 1940s or ’50s, when health care spending absorbed 4 or 5 percent of our national income. But it is 2014. Health care spending now eats up 17 percent of our income. Since the 1970s, observers across the political spectrum have agreed that America will never achieve and maintain a substantial reduction in our uninsured rate, never mind universal coverage, unless we reduce the cost of our health care system. As a candidate and as president, Barack Obama made it clear he understood that.
He made that clear, for example, in response to a question put to him by a woman at a town hall meeting in New Mexico in May 2009. The woman asked why “single payer has been taken off the plate.” Obama prefaced his response by emphasizing the importance of cost containment. “If we simply insured everyone under the current system we couldn’t afford it,” he said. “We’d go broke. We’ve gotta drive down costs.”
But in the rest of his reply, Obama made it clear he had no idea how to reduce health care spending. He said he didn’t support a single-payer system because it was “too disruptive,” and then went on to say there were other ways to cut costs that didn’t require the disruption allegedly caused by single payer. He characterized these other ways as “simple things we can do that will save money,” as if these other ways were as obvious as the nose on your face. He mentioned three examples of these “simple things”: “prevention and wellness programs,” “reimbursing doctors not just for treating people after they get sick but for helping people stay well,” and information technology to reduce “error rates” in physician decision making.
http://www.pnhp.org/print/news/2014/may/why-obamacare-cant-lower-costs

Doubts Raised About Off-Label Use of Subsys, a Strong Painkiller

By KATIE THOMASMAY 13, 2014

lmost overnight, a powerful new painkiller has become a $100 million business and a hot Wall Street story.

But nearly as quickly, questions are emerging about how the drug is being sold, and to whom.

The drug, Subsys, is a form of fentanyl, a narcotic that is often used when painkillers like morphine fail to provide relief. The product was approved in 2012 for a relatively small number of people — cancer patients — but has since become an outsize moneymaker for the obscure company that makes it, Insys Therapeutics. In the last year, the company’s sales have soared and its share price has jumped nearly 270 percent.

Behind that business success is an unusual marketing machine that may have pushed Subsys far beyond the use envisioned by the Food and Drug Administration. The F.D.A. approved Subsys only for cancer patients who are already using round-the-clock painkillers, and warned that it should be prescribed only by oncologists and pain specialists. But just 1 percent of prescriptions are written by oncologists, according to data provided by Symphony Health, which analyzes drug trends. About half of the prescriptions were written by pain specialists, and a wide range of doctors prescribed the rest, including general practice physicians, neurologists and even dentists and podiatrists.

Interviews with several former Insys sales representatives suggest the company, based in Chandler, Ariz., has aggressively marketed the painkiller, including to physicians who did not treat many cancer patients and by paying its sales force higher commissions for selling higher doses of the drug.

Under F.D.A. rules, manufacturers may market prescription drugs only for approved uses. But doctors may prescribe drugs as they see fit. Over the last decade, pharmaceutical companies have paid billions of dollars to settle claims that they encouraged doctors to use drugs for nonapproved treatments, or so-called off-label uses, to increase sales and profits.

http://www.nytimes.com/2014/05/14/business/doubts-raised-about-off-label-use-of-subsys-a-strong-painkiller.html?emc=eta1&_r=1

U.S. Mines Personal Health Data to Aid Emergency Response

By SHERI FINKMAY 15, 2014

The phone calls were part Big Brother, part benevolent parent. When a rare ice storm threatened New Orleans in January, some residents heard from a city official who had gained access to their private medical information. Kidney dialysis patients were advised to seek early treatment because clinics would be closing. Others who rely on breathing machines at home were told how to find help if the power went out.

Those warnings resulted from vast volumes of government data. For the first time, federal officials scoured Medicare health insurance claims to identify potentially vulnerable people and share their names with local public health authorities for outreach during emergencies and disaster drills.

The program is just one of a growing number of public and corporate efforts to take health information far beyond the doctor’s office, offering the promise of better care but also raising concerns about patient privacy.

In some cities, text messages remind parents to get their children vaccinated. Elsewhere, emergency medical services sift records to identify— sometimes to law enforcement officials — “frequent fliers” who take repeated, costly ambulance trips. In New Orleans, a health care information exchange notifies primary care physicians when their patients are admitted to hospitals, offers insurers the ability to sift the data for “high-cost users” and permits authorized individuals to “break the glass” in emergencies — viewing records of patients who have not previously given permission and cannot speak for themselves. And a federal program allows data sharing with public health officials to monitor “mental health conditions” and other illnesses in hazardous situations, like the Deepwater Horizon oil spill.

“There are a lot of sensitivities involved here,” said Kristen Finne, a senior policy analyst at the Department of Health and Human Services. “When we started this idea,” she said, referring to using Medicare data for disaster assistance, “there was a lot of ‘are you crazy?’ ”

“People are pretty shocked we were able to do this,” she said.

Aspects of the Medicare program were tested in New Orleans; in Broome County, N.Y., which includes Binghamton; and in Arizona. The program was presented to state and local public health officials last month. “We are now moving to scale this really across the country,” said Dr. Nicole Lurie, the assistant health secretary for preparedness and response.

The health officials’ intention was to be more proactive in finding vulnerable people like those who suffered in disasters such as Hurricane Katrina and Hurricane Sandy. When government teams knocked on doors last year to verify the data and gauge reactions, nearly all the residents allowed them in. Only those who asked how they were found were told.

About a dozen advocates for people with disabilities who were briefed by officials generally expressed support.

http://www.nytimes.com/2014/05/16/us/us-mines-personal-health-data-to-aid-emergency-response.html?emc=edit_tnt_20140515&nlid=1311158&tntemail0=y&_r=1