First, an analogy to Professor Eismeier, who was worried about sort of 'quasi death panels' coming out of a lack of tests like the PSA test. The PSA test would be like using leeches to treat wounds today. Sure, it may have some small effect on outcomes, but that effect is so insignificant that no insurance company would cover bleeding someone or using leeches as a means of treatment. Same goes for the PSA screeningss in the future. We don't use leeches anymore--they're ineffective. Why should we use the ineffective PSA?
"Time for a reality check. Illegal immigrants are here. They are not eligible for Medicaid, but many still get sick and many get care, often in emergency rooms. The current proposals would likely not stop them from using their money to buy coverage through an insurance exchange, without subsidies. Just as they can do now.
Should we take a harder line? Force people to prove citizenship in emergency rooms? That’s illegal, for good reason. Make verification requirements so onerous that not a single illegal immigrant slips through? Very expensive, and not smart. It would be highly likely to snag deserving citizens — like old people who don’t have their original birth certificates. And besides, we’ve tried that: A House oversight committee reviewed six state Medicaid programs in 2007 and found that verification rules had cost the federal government an additional $8.3 million. They caught exactly eight illegal immigrants."
Emphasis is mine. I think this puts the debate over Joe Wilson's comments in perspective. Just how far are we willing to go--and how much are we willing to spend--to catch people in this country illegally? $1 million per illegal isn't really worth it, if you ask me.
17 comments:
But will bending the cost curve mean that decisions about tests and procedures will move from doctors and patients to health care bureaucrats doing cost benefit analysis with highly aggregated data?
But isn't highly aggregated data...the best kind of data? In the hierarchy of statistical evidence, the best studies are those that take the most broad view to find statistical significance or insignificance.
Treating one patient out of ten thousand with leeches may actually wind up being medically a responsible thing to do, or at least effective in treatment. But we don't go around sticking leeches on everyone as a result, because the statistics say there's no significant difference between populations who receive and who do not receive the treatment.
The studies in questions are flawed, but let's assume they show that in the aggregate, psa testing saves relatively few lives and is not worth the cost. But my doctor, tops in the field, thinks the psa test probably saved my life. In the future, will he be overruled by a bureaucrat trying to bend the cost curve?
Your doctor wouldn't be tops in the field if he or she believed that.
If you have the time, check out Overtreated, by Sharon Brownlee. It addresses how these "common sense" approaches don't stand up to scientific scrutiny or make us healthier...I can't rehash her arguments nearly as well as she makes them in the original text.
That argument is not up to your usual standard Evan. I'll take my chances with a world famous doctor over a pointy headed bureaucrat-- or a number crunching policy analyst.
Professor, some of the best doctors in the world are the ones driving the school of thought in Overtreated. It's why we have our preeminent medical doctors who address public health and overarching trends in medicine - like Jack Wennberg, who received his postgraduate schooling in internal medicine and nephrology from Hopkins and got his medical degree from McGill - two of the best institutions in the world for doctors.
It isn't just a bunch of people with statistics degrees and non-medical backgrounds driving this. Wennberg said this in 1967:
"The basic premise [of the study being conducted] - that medicine was driven by science and by physicians capable of making clinical decisions based on well-established fact and theory - was simply incompatible with the data we saw. It was immediately apparent that suppliers were more important in driving demand than had been previously realized,"
Simply put, 'very good doctors' and 'world class doctors' are not the ones who would ever give you a PSA test. You're constructing a sort of inverse straw man to bolster your argument--an imaginary doctor who demands a procedure in spite of, not in light of, statistical evidence.
Now, if you exhibited some symptoms of prostate cancer--usually tumors, if they're large enough, will have adverse affects--I'm sure the doctor would get a PSA as part of a screening for prostate cancer. But a world-class doctor would not give you a screening that has no impact on your health outcome.
http://www.wellsphere.com/cancer-article/the-psa-test-the-picture-becomes-slightly-clearer/715343
Policy analysis is complicated and rarely produces the definitive results to which true believers aspire.
Would you try to bend the cost curve with data like these?
In cases like that, we wait for more evidence.
I don't see how two competing studies with different methodologies is somehow damning evidence that we can't use evidence to determine how we treat patients. Look at bone marrow replacement therapy for breast cancer. It was ubiquitous 15 years ago and was widely supported by doctors.
But it doesn't have any impact on a woman's health. It's outlandishly expensive. And the only reason it's fallen out of favor as a practice is because people decided to do studies and actually ask if our treatments were working.
Source: http://www.webmd.com/breast-cancer/guide/bone-marrow-transplantation
But who has final say about how to use conflicting or ambiguous studies, doctors or bureaucrats?
Right now, for most of us, insurance companies do.
In the future, I'd want doctors. But doctors can be bureaucrats too--we have plenty of doctors on Medicare advisory boards, VA advisory boards, and the like. There isn't one universe of people who are doctors and one universe of people who are bureaucrats. There is overlap. If the question is what can my doctor do, your doctor can always do whatever he or she wants. But if he or she wants reimbursement for any procedure, whoever provides your insurance--the government or a private insurer--has to approve that treatment.
Yes, and bending the cost curve could mean that more of those decisions will be made not by doctor with their patients but by medical bureaucrats.
"Medical bureaucrats" are doctors too. I think you're parsing language to avoid the point that medical doctors will still be making decisions about care. It isn't like we have computers in back rooms looking at these things and making rigid utilitarian calculations. People who took the Hippocratic Oath are still making these decisions.
Are you sure about the commitment to the Hippocratic Oath?
http://online.wsj.com/article/SB10001424052970203706604574374463280098676.html
Is there any plan in the works to remove the Hippocratic Oath? One academic's musings do not mean that the Oath is going away. Simply saying that someone--even someone prominent--wants a certain policy enacted, or reformed, doesn't mean it's actually going to happen. Betsy McCaughy is dropping a red herring.
If these reforms passed right now, the doctors who determined the care would be bound by the Hippocratic Oath to do no harm. That's just the facts. If you want to engage about speculation about what might happen in the future, well, that discussion can really lead anywhere.
One academic's musings? Isn't he
health-policy adviser at the Office of Management and Budget and a member of the Federal Council on Comparative Effectiveness Research. Scary stuff for us soon to be senior citizens.
Do you have any evidence that the papers McCaughy quoted have made any impact on U.S. policy?
He can write what he wants in an academic setting...in fact, isn't that one of the points of academics, to propose controversial, sometimes out-of-bounds solutions to challenging problems to get us thinking? It's good to have very, very sharp minds who are willing to be the devil's advocate.
Perhaps your argument is with Dr Emanuel, who suggests that "Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records and improving quality of care are merely 'lipstick' cost control, more for show and public relations than for true change." He (and I) would argue that big cost savings will require hard choices about who gets what kind of treatments.
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