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As part of his health care package, President Obama proposed creating an independent commission of medical experts that would determine the medical procedures for which Medicare will pay. The reason is that patients now receive many costly procedures that provide little or no medical benefit. If we can reduce this waste, we can have large savings, while possibly even improving health outcomes. President Obama describes this as promoting good medicine.
He has a case, but there is one problem with this picture. If the plan is to promote good medicine, why are we just doing it for the elderly receiving Medicare? Why don’t we want good medicine for everyone?
Specifically, the government could apply the experts’ judgments on appropriate procedures to any insurance plan that receives government support. This would mean that any plan that enrolls patients with government subsidies would be bound by the expert panel’s judgment. If we are confident that our experts will be acting based on sound medical evidence, why shouldn’t their assessment apply everywhere?
In addition to the "why not" question, there is also a very important reason why we should want everyone else to be treated like Medicare beneficiaries: quality assurance. There is a disturbing tendency among our Washington elites to treat seniors as a species apart. For example, people who complain about high tax rates on the wealthy have no trouble proposing means-testing schemes for Social Security and Medicare that would impose far higher effective tax rates on middle income retirees.
If the same rules for medical procedures were applied to everyone as to the elderly, it would be far less likely that genuinely useful procedures would be excluded from coverage just to save the government a few dollars. With far more eyes on the process, and far more interested parties, we could have much greater confidence that the panel’s decisions were really based on sound evidence.
This raises another important issue about these sorts of medical panels: conflicts of interest. Top medical researchers have a bad habit of taking large consulting fees from folks like pharmaceutical companies, medical supply companies and insurance companies. In many cases, they even hold stakes in these companies.
These medical experts are undoubtedly all very honorable people. However, it simply is not fair to ask the public to trust the health of their loved ones to a medical expert who got a $50,000 check from a company that stands to profit or lose large sums of money depending on their decision.
Any panel must come with strict conflict-of-interest guidelines. For example, something like a complete ban, for at least the prior five years, on any fees from any company directly impacted by the panel’s decision would be a good start.
Of course, strict conflict of interest rules would make it difficult to put together a panel of experts, since virtually all of our top medical researchers routinely accept fees of various sorts from companies in the health sector. The solution might be to put less compromised foreign researchers on these panels until we can produce a crop of domestic researchers with more integrity.
But if the choice is between no panel or a panel comprised of people on the payroll of the drug companies and their ilk, then no panel would be the better outcome. The fact that putting together a conflict-free panel is actually a problem is a testament to the corruption of our health care system. In the country as large as the United States, there should not be any difficulty finding top experts who survive on their salary as a researcher. The vast majority of us survive on considerably less money.
There is one other point about this process that should be beaten back with a sledgehammer. Nothing in this picture has anything to do with rationing. The question here is what procedures government-subsidized insurance will cover. Everyone in the country is free to buy nongovernment-subsidized insurance or pay for any procedure they want out of their own pocket. In that respect, the system is just like the one we have now: If you can afford it, you can get it. Those shrieking about "rationing" are just using scare words to avoid a real debate.
In short, President Obama’s plan to weed out ineffective and wasteful medical procedures is a good one. But we should not single out Medicare beneficiaries as guinea pigs in this adventure, and definitely must ensure that the people to whom we entrust our health are not on the industry payroll.
15 Comments
This is close to the idea of Medicare for everyone. If it is good enough for Medicare, it should be good enough for the rest of us.
Not to worry. Medicare is where the data is. If you want to determine relative efficacy you have to use either Medicare or Ingenix. And when Medicare decides to pay for, the private plans will soon follow. We actually had something similar in the late ’70’s called the Office of Technology Assessment. It published things like “Does peridontal surgery affect tooth loss”? Guess what happened when Reagan came in.
“As part of his health care package, President Obama proposed creating an independent commission of medical experts that would determine the medical procedures for which Medicare will pay. The reason is that patients now receive many costly procedures that provide little or no medical benefit…..”
Amen to that. In the 8 years since I have been on medicare, I received a number of referrals and treatments that were not medically necessary or even useful. If my experience is at all typical I can see huge savings in oversight of medicare.
It depends who’s on the board. Baker points to conflict of interest — how do we know that board members won’t use profit as the yardstick for efficacy? We don’t. That’s why it’s very risky to “insulate from the political process.”
#3 — I’m not on Medicare, but in an HMO run by a Big Insurer; I’m told that I have to have certain blood tests for prescription renewals, even though my results for what’s being tested for haven’t changed in 25 years. Doctors I saw prior to being forced into an HMO did not see a need for this number of tests, but my gatekeeper tells me he has to do them to satisfy his HMO overlords.
Also, I had always thought HMO’s would do well at enhancing communication between doctors, supposedly one of the reasons a gatekeeper has to make referrals to specialists. Well, I have to hand carry results from one to another; somehow, their vaunted electronic record keeping only goes one way: To the HMO denial of care personnel.
I can’t wait for Medicare, so I can chose my doctors, hospitals. Of course, by then it may not be what it is now….
Thank you Dean.
This woman was on NPR’s Fresh Air this very afternoon. She very effectively ran down the public option contained in the current House bill. She was extremely well informed and clearly is a long time student of the health care issues we now face. I did not agree with everything she she said but it was refreshing to hear straight talk on the subject. The piece was about 20 minutes and worth a listen.
OT – From HuffPo:
House Dems To Hold Five Hour, Closed Door Health Care Meeting
An excellent idea: this would help somewhat to curtail insurers’ attempts to dodge coverage of medically necessary care.
To the same end, here’s another modest proposal that occurred to me during our struggles with a for-profit insurance provider over treatment for my wife’s cancer.
The insurer’s business model appeared to be “Delay”–turn down treatments routinely, even when explicitly covered in the employer’s coverage handbooks, lose calls, don’t return messages, get into a weekend if possible. It occurred to me that a certain percentage of patients probably gives up and another percentage dies in the interim. No doubt actuaries have figured all this out and calculated bonuses for turning down and delaying care.
So here is my proposal: life insurance. Make life insurance an integral part of the required coverage for any insurer that sells health insurance policies. Make the payout for the insurance proportionate to the curability of the illness given treatment but large enough to really hurt when someone dies after a company weasels out of its obligations. Make insurance company costs proportional to outcomes.
I love it. Make ‘em want to keep us a live.
Obama may have been refering to late life, life sustaining procedures.
What Obama Really Meant!
We thought my father had good insurance and was in a great hospital ( as per their ads on billboards, commercials and infomercials ) His care was rationed. He died. Sadly in TN & VA profit care is more important than patient care. http://www.wisecountyissues.com/?p=62
The status quo could learn a few things on efficiency and concerned, compassionate health care from Remote Area Medical ( RAM ), a non profit health care system that works. http://www.ramusa.org They were in Wise County, Virginia this weekend helping families who can’t afford the luxury of seeing a doctor.
We must have health care reform now.
Monday, July 27, 2009
BREAKING: Sell-out group of Senate Dems cave to GOP, reach “bipartisan deal” on health care
From AP:
After weeks of secretive talks, a bipartisan group in the Senate edged closer Monday to a health care compromise that omits a requirement for businesses to offer coverage to their workers and lacks a government insurance option that President Barack Obama favors, according to numerous officials.
Like bills drafted by Democrats, the proposal under discussion by six members on the Senate Finance Committee would bar insurance companies from denying coverage to any applicant. Nor could insurers charge higher premiums on the basis of pre-existing medical conditions.
But it jettisons other core Democratic provisions in a reach for bipartisanship on an issue that has so far produced little.
JUST. FRIGGIN’. TYPICAL. No public option. Employers don’t have to offer insurance. So where do the unemployed, the un or underinsured get insurance? Blue Cross? HFCA?
excellent post. and, robspierre, i love your idea of life insurance!!
OK, I’m kind of nervous about this IMAC, as I have a chronic cancer which isn’t studied all that much. But, some specialists have ideas cast in concrete and seem to think all patients react the same. Amazingly, on a bulletin board for this cancer (with medical specialist supervision), patients relate many stories where their reactions, symptoms, etc., do not follow the presumed course.
What happens in some situations with “specialists” determining best treatment is that treatments which work for the majority are then believed to work for everyone, even though a minority react differently and don’t do well on the regimen presumed to work for “everyone.” I’m living proof of that.
So, yes, this kind of best-practice-fits-all scares the hell –and health– out of me.
Also, aging bodies often respond differently to certain treatments and prescription drugs than younger bodies do, so, again, one treatment does not fit all.