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President Barack Obama has proposed the creation of an Institute
for Comparative Effectiveness as a key component of an ambitious
health care reform. The institute would have the authority to
make official determinations of the clinical effectiveness and
cost-effectiveness of medical treatments, procedures, drugs, and
medical devices.
President Obama's initial nominee as Secretary of Health and
Human Services (HHS), former Senator Tom Daschle (D-SD), has
likewise proposed the creation of a supremely powerful Federal
Health Board, which would have similar authority to make decisions
that would be binding on health plans and providers financed by
federal taxpayers, and potentially on private health insurance
coverage. While Senator Daschle has withdrawn his
name from Senate consideration, the concept of such a board or
institute is strongly indicative of the Obama Administration's
policy orientation toward centralized health policy
decision-making.
The U.S. House of Representatives has just passed the $850
billion American Recovery and Reinvestment Act (H.R. 1), the
so-called economic stimulus bill, which would establish a Federal
Coordinating Council for Comparative Effectiveness Research. The
bill would provide $1.1 billion for the new council and delegate
spending authority to the HHS Secretary to investigate the
effectiveness of different drugs and medical devices. The
Senate version of the economic stimulus package contains a similar
provision.
Of course, there is no reason why private-sector or government
officials should not have access to the best information on what
works and what doesn't. Nor is there any reason why such scientific
evaluations should not be widely available to doctors and patients
alike. But studies of the comparative effectiveness of medical
devices, drugs, and technology should be conducted primarily within
the private sector, and there should be no government monopoly over
either the research or the distribution of information. The key
issue is the personal freedom of patients to be able to choose the
health care that, in the professional judgment of their doctors,
best serves their personal needs.
Focus on Medical Technology. Technology, in particular,
can be expensive. Over the past 20 years, health technology
assessment (HTA)–the synthetic coordination of information
assessing medicines and treatments–has become increasingly popular
with policymakers and legislators around the world. Advocates of
HTA invariably believe that such an approach has the capacity to
provide decision-makers in the public and private sectors with
objective information on the value of medical technologies,
devices, and medicines. Driven by concerned perceptions of
"unproven technology," "spiralling costs" and "increasing consumer
expectations," its proponents aim to produce synthesized research
information that they believe sheds light on the effects and costs
of various forms of health technology.
Such an approach, however, would guarantee the incremental
advance of government control of private medical decisions. While
formally touted as an instrument of efficiency and effectiveness,
it would distort scientific research in the service of political or
budgetary objectives while denying individual freedom of choice. In
that sense, this approach would serve as a propaganda tool designed
to legitimize anti-consumerist rationing.
Comparative Effectiveness in Health
Care: How It Started
The intellectual roots of effectiveness research can be traced
back to mid-18th century Scotland and the "arithmetical medicine"
practiced by the graduates of the Edinburgh medical school. It was
there that James Lind famously undertook a controlled trial of six
separate treatments for scurvy. During the 1830s, Pierre
Louis developed the méthode numérique in
Paris, whereby he demonstrated that phlebotomy did not actually
improve the survival rates of patients suffering from
pneumonia.
At the beginning of the 20th century, Ernest Codman, an American
physician, founded what is today known as "outcomes management" in
patient care. Shunned by established institutions, he set up his
own unit, the End Result Hospital. In line with his teachingsand
the findings from this unit, end results were made public in
a privately published book, A Study in Hospital
Efficiency. Of 337 patients discharged from the
hospital between 1911 and 1916, Codman recorded and publicized 123
errors.
In England, the 1930s saw the development of health services
research. In a world increasingly obsessed with egalitarian
uniformity, J. A. Glover found a tenfold variation in
tonsillectomy. Subsequently, following several decades of
socialized health care in the United Kingdom, the 1970s and 1980s
witnessed the release of a range of studies that highlighted wide
geographical variations in general medical admissions including
operations such as appendectomy, caesarean section,
cholecystectomy, hysterectomy, tonsillectomy, and prostatectomy. Such
variations not only demonstrated the inequities of the National
Health Service (NHS), but also raised questions about the probity
and cost-effectiveness of many of its treatments.
Following the publication of Archie Cochrane's Effectiveness
and Efficiency: Random Reflections on Health Services in the
United States, researchers demonstrated large variations in the
rates of prostatectomy for patients with benign prostatic
hyperplasia. This work and others suggested that such
variations "meant either under-provision in some places and/or
over-provision (and possibly ineffective treatment) in others."
While "comparative effectiveness" builds on skepticism, the
investigation of variations, randomized control trials, and
cost-benefit analysis, its reviews purport to be systematic. As
such, they attempt to go beyond the more narrative-based reviews
that used to dominate the typical review article in medical
literature.
Comparative Effectiveness: The
Rationale
In recent decades, health care has advanced in significant ways.
Across the developed world, not only has medical knowledge
progressed, but investment in equipment and drugs has delivered
unprecedented gains. Treatments are safer and more effective than
ever before. Quality of life and life expectancy have been
enhanced. Alongside aging populations has come the world of
ever-increasing consumer expectations.
The rapid growth of medical knowledge and technology means it is
much harder for doctors and other health care providers to keep up
to date. Indeed, the problem of information and practice
transference is rendered almost impossible by the fact that health
care is now a highly statist and corporatist venture. Today, there
is no such thing as a free market in health care, and many of the
problems popularly associated with it are in fact the result of
state failure.
Today, in virtually every country in the world, health care is
heavily influenced by government policy and fosters professional
monopoly of supply and strict top-down regulation. While there is
nothing inherent in health care that guarantees such an outcome,
governments, either actively or passively, grant special
legislative favor to interest groups when it comes to people's
medical treatments and insurance.
The idea that government is intrinsically a superior agent, over
and above a spontaneous and free market, is groundless. As David
Friedman, a professor of law at Santa Clara University in
California, has argued, both the notion of market failure in health
economics and its popularity with most opinion leaders have arisen
because many health policy analysts "interpret the problem in terms
of fairness rather than efficiency." This almost unconscious
adherence to the notion of market failure in health care is rooted
in:
the error of judging a system by the comparison between its
outcome and the best outcome that can be described, rather than
judging it by a comparison between its outcome and the outcome that
would actually be produced by the best alternative system
available. If, as seems likely, all possible sets of institutions
fall short of producing perfect outcomes, then a policy of
comparing observed outcomes to ideal ones will reject any existing
system…. The question we should ask, and try to answer, is
not what outcome would be ideal but what outcome we can expect from
each of various alternative sets of institutions, and which, from
that limited set of alternatives, we prefer.… My conclusion
is that there is no good reason to expect government involvement in
the medical market, either the extensive involvement that now
exists or the still more extensive involvement that many advocated,
to produce desirable results.
Curiously, it is within the context of government control and
anti-competitive corporatism that new and innovative medical
treatments are met with initiatives for even more rationing by
government officials, as well as other highly regulated players
including private medical insurers. In recent years, many countries
have introduced comparative effectiveness or HTA programs,
ostensibly to improve their decision-making and their allocation of
relatively scarce medical resources. In reality, many politicians
and officials have done so not least because they are trying to get
themselves off the hook of past promises they made concerning the
provision of comprehensive, unlimited, or, as in the case of the
United Kingdom, seemingly "free" health care at the point of
service.
Since extensive government intervention has distorted health
care markets and has made it impossible for individuals to
determine a clear and transparent value of the costs and benefits
of health care technology through a normally functioning price
system, the proponents of comparative effectiveness, or health
technology assessment, have instead resorted to a predictably
pseudoscientific methodology to give their bureaucratic
determinations a sheen of objectivity. As with other forms of
centralized government planning, the practitioners of these
bureaucratic arts attempt to capture and mathematically profile and
model their assessments; in assessing health technology, they seek
"to compare and prioritize new technologies based on different
units that aggregate…benefits."
In a study of HTA for the Stockholm Network, a prominent
European think tank, research has focused on these assessments in
terms of the value of human life:
In HTA, the dominant aggregate natural unit is called
quality-adjusted life years (QALYs). Generally, QALYs factor in
both the quantity and the quality of life generated by new health
care interventions. It is the arithmetic calculation of life
expectancy and a measure of the quality of the remaining life
years…. To date QALYs are the preferred indicator of HTAs
calculations, although one may find additional tools in use by HTA
bodies such as HRQol ("health related quality of life," which
considers physical function, social function, cognitive function,
distress, pain: in brief, anything to do with quality of life),
DALYs ("disability life adjusted years"–of life lost due to
premature mortality in the population and the years lost due to
disability for incidents of the studied health condition), and
healthy-year equivalents (HYEs).
Despite the pretense of scientific objectivity, this type of
health technology assessment is nothing of the sort. It is designed
primarily to provide policymakers with a legitimizing rubric by
which they can mimic a few elements of the market and therefore
deploy a degree of fake economic rationality in justifying their
decisions. In this way, practitioners of HTA attempt to balance the
requirement to provide innovative health care technologies with
ham-fisted efforts at controlling the costs of those
technologies.
Consider the quality of human life and lifespan. The use of
QALYs is pseudoscience. It is nothing more than a tool for central
planning that attempts to objectify what is inherently subjective.
The limited attempts to capture accurately the various "units of
healthcare benefit" mean that there is an inevitable gulf between
the theoretical underpinnings of QALYs and the actual behavior of
ordinary people. Moreover, the artificial prioritization of
so-called cost-based considerations by practitioners of health
technology assessment is invariably made at the expense of other
considerations. As Dr. Meir Pugatch and Francesca Ficai of the
Stockholm Network note, "Thus, a decision to prioritize a less
therapeutically effective medicine because of cost-based
considerations over an effective, but more expensive, medicine
could lead to some serious political, social and moral dilemmas."
Not only is this type of health technology assessment
methodologically flawed: It is incompatible with personal freedom
and contradicts the subjective choices of genuine economic agents.
When deployed at the national level through the power of a
government agency, it is inevitably subject to additional political
pressures. Indeed, in 2009, it is clear that national organizations
that conduct these assessments–such as the National Institute for
Health and Clinical Excellence in the United Kingdom or the
Institute for Quality and Efficiency in Health Care in Germany–are
in the business of rationing health care technologies so that they
mesh with the politically fixed budgetary allocations of the
national government.
Today, it is clear that the political economy of these
government bodies means that their structures, processes, and
pseudoscientific constructs have a significant and detrimental
impact on the practice of, and even the public discourse on, health
care. Far from reflecting scientific rationality and economics,
health technology assessments often reflect either politically
driven social judgments of the decision-makers in these agencies
or, worse, a thinly veiled attempt to accommodate whatever
political pressures happen to be momentarily dominant.
How Comparative Effectiveness Works in
Europe
According to the International Network of Agencies for Health
Technology Assessments (INAHTA), many industrialized
countries have bodies that are charged with health technology
assessments or comparative effectiveness studies. Despite this, the
evolution of these bodies and their responsibilities at the
national decision-making level has been far from uniform.
For example, some of these bodies have an advisory role. They
make reimbursements or pricing recommendations to a national or
regional governing body, as is the case in Denmark. Others have a
more explicit regulatory role. They are accountable to government
ministers and are responsible for listing and pricing medicines and
devices. This is the case in France, Germany, and the United
Kingdom.
The United Kingdom. The experience of the United Kingdom
in making the difficult decisions about what kind of health care
technologies, devices, drugs, and medical treatments and procedures
should be favored in Britain's National Health Service has been
cited favorably by Senator Daschle.
The NHS was established in 1948. It is a single-payer health
care system, directly administered by the British government,
funded through taxation, and provided mainly by public-sector
institutions. Because the NHS is a fully nationalized entity, the
central government specifies the capital and current budgets of its
regional health authorities and determines the expenditure on drugs
by controlling the budgets given to each general practitioner.
Overall, NHS health care is rationed through long waiting lists
and, in some cases, omission of various treatments.
For the British government, the practice of HTA facilitates
rationing by delay. It is a tool that aims to ensure that expensive
new technologies are initially provided only in hospitals that have
the technical capacity to evaluate them. While the NHS Research and
Development Health Technology Assessment Programme is funded by the
Department of Health and, according to its criteria, researches the
costs, effectiveness, and impact of health technologies, the
Medicines and Healthcare Products Regulatory Agency (MHRA) ensures
that drugs and devices are safe.
In 1999, the government went a step further and set up the
National Institute of Health and Clinical Excellence (NICE). At
its heart is the Centre for Health Technology Evaluation that
issues formal guidance on the use of new and existing medicines
based on rigid and proscriptive "economic" and clinical formulas.
With the NHS obliged to adhere to NICE's pronouncements, criticism
of NICE has been ceaseless, particularly from various patient
organizations.
NICE is a controversial body. It has tried repeatedly to stop
breast cancer patients from receiving the powerful breakthrough
drug Herceptin and patients with Alzheimer's disease from receiving
the drug Aricept. The criteria by which this agency makes its
decisions have been kept largely secret from the public. As is
inevitable with any nationalized health care system, life-extending
medicines such as those to treat renal cancers are refused on the
grounds of limited resources and the need to make decisions based
not on genuine market economics but on an artificial assessment of
the benefit that may be gained by the patient and society "as a
whole."
In 2001, NICE deliberately restricted state-insured sufferers of
multiple sclerosis from receiving the innovative medicine Beta
Interferon. Claiming that its relatively high price jeopardized the
efficacy of the NHS, patients with the more severe forms of the
disease were told that they would have to go on suffering in the
name of politically defined equity.
In more recent years, patients with painful and debilitating
forms of rheumatoid arthritis have been informed by NICE that in
many instances they will not be allowed to receive a sequential
range of medicines that have often been proved to be of significant
benefit. Instead, the institute decreed that "people will be
prevented from trying a second anti-TNF treatment if the first does
not work for their condition."
Similarly, in August 2008, patients with kidney cancer continued
to be denied effective treatments designed to prolong their lives,
often by months or even a few years. The calculations used by NICE
have been systematically disputed by clinical experts who are more
concerned with patient welfare than with vote-seeking, but the
institute has also come under fire for not involving doctors who
are active on the front line of medicine: "With Sutent for
instance, there was just one oncologist on the panel."
In January 2009, patients with osteoporosis also fell foul of
NICE. The institute declared that only a small minority of patients
with this debilitating disease would receive the medicine Protelos,
and even they would receive it only as an extreme last resort.
While clinicians and osteoporosis support groups have pointed out
that more than 70,000 hip fractures result in 13,000 premature
deaths in the U.K. each year and that these otherwise avoidable
episodes needlessly cost the NHS billions of pounds, not only are
patients being denied necessary treatments, but taxpayers' money is
wasted.
Indeed, according to its annual reports and accounts, NICE is
now spending more money on communicating its decisions than would
be spent if it allowed patients access to many of the medicines it
is so busy denying them. The money that the institute now spends on
public relations campaigns "could have paid for 5,000 Alzheimer's
sufferers to get £2.50-a-day drugs for a year," according to
The Daily Mail.
Devoid of a market and the language of price, this top-down
system ironically ignores many of the societal costs associated
with failure to treat severe illness, such as illness-related
unemployment. Moreover, the fact that preventing access to more
costly medicines may save money in the short term overlooks the
costs for the future. If older medicines lead to more rapid
deterioration of a condition, the effect could be a more expensive
hospital or nursing home episode later.
Denmark. The Danish health care system is
completely state-funded, with public provision of hospital beds
representing more than 90 percent of thehospital sector. Under the
Healthcare Act, citizens are covered for all or part of
expenditures for treatment, including reimbursement for all
pharmaceutical products listed with the Danish Medicines Agency.
Therefore, there is no need for price regulation of drugs. With
central and municipal government having significant control of the
funding and provision of health care, the acquisition of new
technology is left initially to the five regions that run the
hospitals.
Denmark's national HTA system was explicitly established on the
basis of its making prioritized resource-allocation decisions.
Carried out by the unit known as the Danish Centre for Evaluation
and Health Technology Assessment (DACEHTA), it operates within the
framework of the National Board of Health (NBH), itself a part of
the Danish Ministry of Health. In reality, this means
that "he Ministry keeps a close watch on it in order to
neutralize 'expensive' healthcare technologies, as their adoption
results in requests for extra funding from the regions."
France. In France, health care is a statutory
right enshrined in the Constitution of the Fifth Republic. Unlike
in Denmark or the United Kingdom, however, French health care is
financed mainly by social insurance and delivered by a mixture of
public and private providers. While two-thirds of French hospitals
are state-owned, one-third are private, with half of the latter
group being not-for-profit.
There have been various attempts in recent years to extend
government control of health care costs. In 1991, the French
government extended its Health Map system by which it controls the
capital construction of all hospitals as well as their budgets, the
purchase of medical equipment, the rates charged by private
hospitals, the number of pharmacies per head, and even the price of
drugs.
In 2005, the government went a stage further with the
establishment of a centralized High Health Authority. While this
body has had only a limited impact–and France continues to enjoy a
comparatively higher diffusion rate for new technologies than is
found in many other countries in Europe–it is nevertheless
designed to stipulate the benefits of medicines and determine their
price-reimbursement levels. As such, it is set to raise the focus
on cost-containment and bring its decision-making under closer
state control.
Germany. As in France, health care in Germany is
financed primarily by social insurance and provided by a mixture of
public and private providers. While all services are contracted
instead of being provided directly by the government, more than 10
percent of Germans opt for full private medical insurance.
Providing a potent source of exit from the state, the regulated
private sector puts pressure on the government to ensure that the
sectoral differences in service do not become so wide that
ever-larger numbers of young, high-income consumers defect by going
private and delegitimizing a central pillar of the Bismarckian
philosophy.
While the pressure to maintain some semblance of parity with the
private sector meant that state spending rose dramatically for many
years after the introduction of a formal reference pricing system
in 1989, the strategic objective of the German Ministry of Health
has been to reduce supply, particularly through the use ofpublished
positive and negative lists concerning medicines and treatments.
Through these lists, pressure is applied to the statutory sick
funds to control costs.
It is in this context that health technology assessment has
played an ever-greater role in German health policy since the
1990s. In 1990, the Office of Technology Assessment at the German
Parliament (TAB) was established, and in 2004, the government set
up the Institute for Quality and Economic Efficiency in the
Healthcare Sector (IQWiG).
Tasked with the central goal of efficiency, IQWiG investigates
and stipulates which therapeutic and diagnostic services are
appropriate. Disseminating its pronouncements to
various self-governing bodies, its information is used concerning
the coverage of technologies in the benefits catalogue. With such
ventures being funded primarily by the German Ministry for Health
and Social Affairs, assessment bodies can refuse a hospital's claim
for reimbursement for the unauthorized use of new technology.
Lessons for American Policymakers
There is a pervasive European mythology: a widespread belief
that American health care is rooted in the free market. In reality,
much of American health care is a highly planned, regulated, and
government-funded system. Through major entitlement and welfare
programs such as Medicare and Medicaid, which contribute to rapidly
growing American health care costs, government takes a historically
higher proportion of gross domestic product than does even the
British NHS. Moreover, by virtue of the structure and financing of
private-sector health insurance, there is little consumer control
over health care dollars.
Nonetheless, the United States is not only a major consumer of
health care services, but also the world's largest producer of
medical technology. Investment in new medical technology is
comparatively high, as is its rate of diffusion: "This is
demonstrated by cross-national examinations of the comparative
availability of selected medical technologies such as radiation
therapy and open-heart surgery. Measured in units per million, the
United States experiences levels of availability up to three times
greater than in Canada and Germany."
During the presidential campaign, Barack Obama proposed an
Institute for Comparative Effectiveness that would make formal
recommendations on medical technologies, devices, and drugs. In
Congress, champions of comprehensive overhaul of U.S. health care
favor policies that would explicitly accelerate America's
trajectory downward toward a European-style medical
interventionism.
Fearing the impact of the rising costs of Medicare, Medicaid,
and the highly regulated arrangements of the private insurance
sector, many American legislators and other top policymakers are
becoming attracted to the idea of a body that would make top-down
pronouncements on the cost-effectiveness of new medical
technologies. The idea of a statutorily created agency charged with
system-wide cost containment and rationing of medical services and
technologies is becoming surprisingly fashionable in Washington
policy circles.
The implications of this trend are alarming for U.S. citizens,
particularly when one considers that the technology a society uses
reflects the wider and underlying incentive structures it adopts
for using it: "An incentive structure that encourages providers to
trade off the costs and benefits of health care gives providers
little incentive to use expensive technologies and thus researchers
will have little incentive to create it."
In the long term, a statist, centralized control of medical
technology offers little if any regulatory benefit. Through its own
logic, it not only stifles innovation, but also, in doing so, ends
up precluding those very inventions that could turn out to be of
immeasurable benefit to individuals and to society in general.
If comparative effectiveness and health technology assessment
especially are to be useful, they must be generated primarily by
the private sector on a competitive and non-coercive basis. In
avoiding the imposition of a uniformity of rules that comes with
government intervention, physicians and other medical professionals
would and should remain free to pick and choose from the best
practices and professional insights into the treatment of medical
conditions as they see fit (with, of course, the informed consent
of their patients).
It is only by returning health care to a genuinely
patient-centered and consumer-driven health care marketplace that
information, innovation, and best practice will permeate the
complex array of health care arrangements in both the public and
the private sectors. It is only through open competition and the
economic discipline of the free market that real progress and
productivity can be secured.
Therefore, in framing a policy on comparative effectiveness,
America's policymakers should be governed by four principles:
- They should reject the statutory creation of a board,
council, or institute that would centralize government control of
patient access to drugs, devices, medical technologies, treatments,
or procedures. This is especially the case if such an agency
were to have the power to override the considered judgment of
competing professional expertise, especially the professional
judgment of a patient's attending physician. - Comparative effectiveness research and health technology
assessments should be undertaken primarily by the private
sector. While government can contribute to research efforts and
promote the widespread availability of the best information, it
must not exercise monopoly power over the conduct of research
itself or the distribution of information. - Comparative effectiveness research should be
patient-centered and supportive of quality and value, not focused
simply on cost-containment. In this respect, it should foster
scientific advances, health information technology, and the
emerging science of personalized medicine. - Comparative effectiveness research must move beyond
randomized clinical trials and embrace practical clinical
trials. It should include observational data, and its
methodologies should fully address issues such as the validity and
applicability of findings.
Conclusion
As is clear from the British experience and other international
examples, a comparative effectiveness strategy that relies on
central planning and coercion would not only be counterproductive
in the long run–because it would undermine the incentives for
medical innovation–but would also lead to the imposition of cost
constraints that would worsen patients' medical conditions and
damage the quality of their lives.
Helen Evans, Ph.D., is a citizen of
the United Kingdom. A registered general nurse, she is the Director
of Nurses for Reform and a Health Fellow with the Adam Smith
Institute of London, England.
President Barack Obama has proposed the creation of an Institute
for Comparative Effectiveness as a key component of an ambitious
health care reform. The institute would have the authority to
make official determinations of the clinical effectiveness and
cost-effectiveness of medical treatments, procedures, drugs, and
medical devices.
President Obama's initial nominee as Secretary of Health and
Human Services (HHS), former Senator Tom Daschle (D-SD), has
likewise proposed the creation of a supremely powerful Federal
Health Board, which would have similar authority to make decisions
that would be binding on health plans and providers financed by
federal taxpayers, and potentially on private health insurance
coverage. While Senator Daschle has withdrawn his
name from Senate consideration, the concept of such a board or
institute is strongly indicative of the Obama Administration's
policy orientation toward centralized health policy
decision-making.
The U.S. House of Representatives has just passed the $850
billion American Recovery and Reinvestment Act (H.R. 1), the
so-called economic stimulus bill, which would establish a Federal
Coordinating Council for Comparative Effectiveness Research. The
bill would provide $1.1 billion for the new council and delegate
spending authority to the HHS Secretary to investigate the
effectiveness of different drugs and medical devices. The
Senate version of the economic stimulus package contains a similar
provision.
Of course, there is no reason why private-sector or government
officials should not have access to the best information on what
works and what doesn't. Nor is there any reason why such scientific
evaluations should not be widely available to doctors and patients
alike. But studies of the comparative effectiveness of medical
devices, drugs, and technology should be conducted primarily within
the private sector, and there should be no government monopoly over
either the research or the distribution of information. The key
issue is the personal freedom of patients to be able to choose the
health care that, in the professional judgment of their doctors,
best serves their personal needs.
Focus on Medical Technology. Technology, in particular,
can be expensive. Over the past 20 years, health technology
assessment (HTA)–the synthetic coordination of information
assessing medicines and treatments–has become increasingly popular
with policymakers and legislators around the world. Advocates of
HTA invariably believe that such an approach has the capacity to
provide decision-makers in the public and private sectors with
objective information on the value of medical technologies,
devices, and medicines. Driven by concerned perceptions of
"unproven technology," "spiralling costs" and "increasing consumer
expectations," its proponents aim to produce synthesized research
information that they believe sheds light on the effects and costs
of various forms of health technology.
Such an approach, however, would guarantee the incremental
advance of government control of private medical decisions. While
formally touted as an instrument of efficiency and effectiveness,
it would distort scientific research in the service of political or
budgetary objectives while denying individual freedom of choice. In
that sense, this approach would serve as a propaganda tool designed
to legitimize anti-consumerist rationing.
Comparative Effectiveness in Health
Care: How It Started
The intellectual roots of effectiveness research can be traced
back to mid-18th century Scotland and the "arithmetical medicine"
practiced by the graduates of the Edinburgh medical school. It was
there that James Lind famously undertook a controlled trial of six
separate treatments for scurvy. During the 1830s, Pierre
Louis developed the méthode numérique in
Paris, whereby he demonstrated that phlebotomy did not actually
improve the survival rates of patients suffering from
pneumonia.
At the beginning of the 20th century, Ernest Codman, an American
physician, founded what is today known as "outcomes management" in
patient care. Shunned by established institutions, he set up his
own unit, the End Result Hospital. In line with his teachingsand
the findings from this unit, end results were made public in
a privately published book, A Study in Hospital
Efficiency. Of 337 patients discharged from the
hospital between 1911 and 1916, Codman recorded and publicized 123
errors.
In England, the 1930s saw the development of health services
research. In a world increasingly obsessed with egalitarian
uniformity, J. A. Glover found a tenfold variation in
tonsillectomy. Subsequently, following several decades of
socialized health care in the United Kingdom, the 1970s and 1980s
witnessed the release of a range of studies that highlighted wide
geographical variations in general medical admissions including
operations such as appendectomy, caesarean section,
cholecystectomy, hysterectomy, tonsillectomy, and prostatectomy. Such
variations not only demonstrated the inequities of the National
Health Service (NHS), but also raised questions about the probity
and cost-effectiveness of many of its treatments.
Following the publication of Archie Cochrane's Effectiveness
and Efficiency: Random Reflections on Health Services in the
United States, researchers demonstrated large variations in the
rates of prostatectomy for patients with benign prostatic
hyperplasia. This work and others suggested that such
variations "meant either under-provision in some places and/or
over-provision (and possibly ineffective treatment) in others."
While "comparative effectiveness" builds on skepticism, the
investigation of variations, randomized control trials, and
cost-benefit analysis, its reviews purport to be systematic. As
such, they attempt to go beyond the more narrative-based reviews
that used to dominate the typical review article in medical
literature.
Comparative Effectiveness: The
Rationale
In recent decades, health care has advanced in significant ways.
Across the developed world, not only has medical knowledge
progressed, but investment in equipment and drugs has delivered
unprecedented gains. Treatments are safer and more effective than
ever before. Quality of life and life expectancy have been
enhanced. Alongside aging populations has come the world of
ever-increasing consumer expectations.
The rapid growth of medical knowledge and technology means it is
much harder for doctors and other health care providers to keep up
to date. Indeed, the problem of information and practice
transference is rendered almost impossible by the fact that health
care is now a highly statist and corporatist venture. Today, there
is no such thing as a free market in health care, and many of the
problems popularly associated with it are in fact the result of
state failure.
Today, in virtually every country in the world, health care is
heavily influenced by government policy and fosters professional
monopoly of supply and strict top-down regulation. While there is
nothing inherent in health care that guarantees such an outcome,
governments, either actively or passively, grant special
legislative favor to interest groups when it comes to people's
medical treatments and insurance.
The idea that government is intrinsically a superior agent, over
and above a spontaneous and free market, is groundless. As David
Friedman, a professor of law at Santa Clara University in
California, has argued, both the notion of market failure in health
economics and its popularity with most opinion leaders have arisen
because many health policy analysts "interpret the problem in terms
of fairness rather than efficiency." This almost unconscious
adherence to the notion of market failure in health care is rooted
in:
the error of judging a system by the comparison between its
outcome and the best outcome that can be described, rather than
judging it by a comparison between its outcome and the outcome that
would actually be produced by the best alternative system
available. If, as seems likely, all possible sets of institutions
fall short of producing perfect outcomes, then a policy of
comparing observed outcomes to ideal ones will reject any existing
system…. The question we should ask, and try to answer, is
not what outcome would be ideal but what outcome we can expect from
each of various alternative sets of institutions, and which, from
that limited set of alternatives, we prefer.… My conclusion
is that there is no good reason to expect government involvement in
the medical market, either the extensive involvement that now
exists or the still more extensive involvement that many advocated,
to produce desirable results.
Curiously, it is within the context of government control and
anti-competitive corporatism that new and innovative medical
treatments are met with initiatives for even more rationing by
government officials, as well as other highly regulated players
including private medical insurers. In recent years, many countries
have introduced comparative effectiveness or HTA programs,
ostensibly to improve their decision-making and their allocation of
relatively scarce medical resources. In reality, many politicians
and officials have done so not least because they are trying to get
themselves off the hook of past promises they made concerning the
provision of comprehensive, unlimited, or, as in the case of the
United Kingdom, seemingly "free" health care at the point of
service.
Since extensive government intervention has distorted health
care markets and has made it impossible for individuals to
determine a clear and transparent value of the costs and benefits
of health care technology through a normally functioning price
system, the proponents of comparative effectiveness, or health
technology assessment, have instead resorted to a predictably
pseudoscientific methodology to give their bureaucratic
determinations a sheen of objectivity. As with other forms of
centralized government planning, the practitioners of these
bureaucratic arts attempt to capture and mathematically profile and
model their assessments; in assessing health technology, they seek
"to compare and prioritize new technologies based on different
units that aggregate…benefits."
In a study of HTA for the Stockholm Network, a prominent
European think tank, research has focused on these assessments in
terms of the value of human life:
In HTA, the dominant aggregate natural unit is called
quality-adjusted life years (QALYs). Generally, QALYs factor in
both the quantity and the quality of life generated by new health
care interventions. It is the arithmetic calculation of life
expectancy and a measure of the quality of the remaining life
years…. To date QALYs are the preferred indicator of HTAs
calculations, although one may find additional tools in use by HTA
bodies such as HRQol ("health related quality of life," which
considers physical function, social function, cognitive function,
distress, pain: in brief, anything to do with quality of life),
DALYs ("disability life adjusted years"–of life lost due to
premature mortality in the population and the years lost due to
disability for incidents of the studied health condition), and
healthy-year equivalents (HYEs).
Despite the pretense of scientific objectivity, this type of
health technology assessment is nothing of the sort. It is designed
primarily to provide policymakers with a legitimizing rubric by
which they can mimic a few elements of the market and therefore
deploy a degree of fake economic rationality in justifying their
decisions. In this way, practitioners of HTA attempt to balance the
requirement to provide innovative health care technologies with
ham-fisted efforts at controlling the costs of those
technologies.
Consider the quality of human life and lifespan. The use of
QALYs is pseudoscience. It is nothing more than a tool for central
planning that attempts to objectify what is inherently subjective.
The limited attempts to capture accurately the various "units of
healthcare benefit" mean that there is an inevitable gulf between
the theoretical underpinnings of QALYs and the actual behavior of
ordinary people. Moreover, the artificial prioritization of
so-called cost-based considerations by practitioners of health
technology assessment is invariably made at the expense of other
considerations. As Dr. Meir Pugatch and Francesca Ficai of the
Stockholm Network note, "Thus, a decision to prioritize a less
therapeutically effective medicine because of cost-based
considerations over an effective, but more expensive, medicine
could lead to some serious political, social and moral dilemmas."
Not only is this type of health technology assessment
methodologically flawed: It is incompatible with personal freedom
and contradicts the subjective choices of genuine economic agents.
When deployed at the national level through the power of a
government agency, it is inevitably subject to additional political
pressures. Indeed, in 2009, it is clear that national organizations
that conduct these assessments–such as the National Institute for
Health and Clinical Excellence in the United Kingdom or the
Institute for Quality and Efficiency in Health Care in Germany–are
in the business of rationing health care technologies so that they
mesh with the politically fixed budgetary allocations of the
national government.
Today, it is clear that the political economy of these
government bodies means that their structures, processes, and
pseudoscientific constructs have a significant and detrimental
impact on the practice of, and even the public discourse on, health
care. Far from reflecting scientific rationality and economics,
health technology assessments often reflect either politically
driven social judgments of the decision-makers in these agencies
or, worse, a thinly veiled attempt to accommodate whatever
political pressures happen to be momentarily dominant.
How Comparative Effectiveness Works in
Europe
According to the International Network of Agencies for Health
Technology Assessments (INAHTA), many industrialized
countries have bodies that are charged with health technology
assessments or comparative effectiveness studies. Despite this, the
evolution of these bodies and their responsibilities at the
national decision-making level has been far from uniform.
For example, some of these bodies have an advisory role. They
make reimbursements or pricing recommendations to a national or
regional governing body, as is the case in Denmark. Others have a
more explicit regulatory role. They are accountable to government
ministers and are responsible for listing and pricing medicines and
devices. This is the case in France, Germany, and the United
Kingdom.
The United Kingdom. The experience of the United Kingdom
in making the difficult decisions about what kind of health care
technologies, devices, drugs, and medical treatments and procedures
should be favored in Britain's National Health Service has been
cited favorably by Senator Daschle.
The NHS was established in 1948. It is a single-payer health
care system, directly administered by the British government,
funded through taxation, and provided mainly by public-sector
institutions. Because the NHS is a fully nationalized entity, the
central government specifies the capital and current budgets of its
regional health authorities and determines the expenditure on drugs
by controlling the budgets given to each general practitioner.
Overall, NHS health care is rationed through long waiting lists
and, in some cases, omission of various treatments.
For the British government, the practice of HTA facilitates
rationing by delay. It is a tool that aims to ensure that expensive
new technologies are initially provided only in hospitals that have
the technical capacity to evaluate them. While the NHS Research and
Development Health Technology Assessment Programme is funded by the
Department of Health and, according to its criteria, researches the
costs, effectiveness, and impact of health technologies, the
Medicines and Healthcare Products Regulatory Agency (MHRA) ensures
that drugs and devices are safe.
In 1999, the government went a step further and set up the
National Institute of Health and Clinical Excellence (NICE). At
its heart is the Centre for Health Technology Evaluation that
issues formal guidance on the use of new and existing medicines
based on rigid and proscriptive "economic" and clinical formulas.
With the NHS obliged to adhere to NICE's pronouncements, criticism
of NICE has been ceaseless, particularly from various patient
organizations.
NICE is a controversial body. It has tried repeatedly to stop
breast cancer patients from receiving the powerful breakthrough
drug Herceptin and patients with Alzheimer's disease from receiving
the drug Aricept. The criteria by which this agency makes its
decisions have been kept largely secret from the public. As is
inevitable with any nationalized health care system, life-extending
medicines such as those to treat renal cancers are refused on the
grounds of limited resources and the need to make decisions based
not on genuine market economics but on an artificial assessment of
the benefit that may be gained by the patient and society "as a
whole."
In 2001, NICE deliberately restricted state-insured sufferers of
multiple sclerosis from receiving the innovative medicine Beta
Interferon. Claiming that its relatively high price jeopardized the
efficacy of the NHS, patients with the more severe forms of the
disease were told that they would have to go on suffering in the
name of politically defined equity.
In more recent years, patients with painful and debilitating
forms of rheumatoid arthritis have been informed by NICE that in
many instances they will not be allowed to receive a sequential
range of medicines that have often been proved to be of significant
benefit. Instead, the institute decreed that "people will be
prevented from trying a second anti-TNF treatment if the first does
not work for their condition."
Similarly, in August 2008, patients with kidney cancer continued
to be denied effective treatments designed to prolong their lives,
often by months or even a few years. The calculations used by NICE
have been systematically disputed by clinical experts who are more
concerned with patient welfare than with vote-seeking, but the
institute has also come under fire for not involving doctors who
are active on the front line of medicine: "With Sutent for
instance, there was just one oncologist on the panel."
In January 2009, patients with osteoporosis also fell foul of
NICE. The institute declared that only a small minority of patients
with this debilitating disease would receive the medicine Protelos,
and even they would receive it only as an extreme last resort.
While clinicians and osteoporosis support groups have pointed out
that more than 70,000 hip fractures result in 13,000 premature
deaths in the U.K. each year and that these otherwise avoidable
episodes needlessly cost the NHS billions of pounds, not only are
patients being denied necessary treatments, but taxpayers' money is
wasted.
Indeed, according to its annual reports and accounts, NICE is
now spending more money on communicating its decisions than would
be spent if it allowed patients access to many of the medicines it
is so busy denying them. The money that the institute now spends on
public relations campaigns "could have paid for 5,000 Alzheimer's
sufferers to get £2.50-a-day drugs for a year," according to
The Daily Mail.
Devoid of a market and the language of price, this top-down
system ironically ignores many of the societal costs associated
with failure to treat severe illness, such as illness-related
unemployment. Moreover, the fact that preventing access to more
costly medicines may save money in the short term overlooks the
costs for the future. If older medicines lead to more rapid
deterioration of a condition, the effect could be a more expensive
hospital or nursing home episode later.
Denmark. The Danish health care system is
completely state-funded, with public provision of hospital beds
representing more than 90 percent of thehospital sector. Under the
Healthcare Act, citizens are covered for all or part of
expenditures for treatment, including reimbursement for all
pharmaceutical products listed with the Danish Medicines Agency.
Therefore, there is no need for price regulation of drugs. With
central and municipal government having significant control of the
funding and provision of health care, the acquisition of new
technology is left initially to the five regions that run the
hospitals.
Denmark's national HTA system was explicitly established on the
basis of its making prioritized resource-allocation decisions.
Carried out by the unit known as the Danish Centre for Evaluation
and Health Technology Assessment (DACEHTA), it operates within the
framework of the National Board of Health (NBH), itself a part of
the Danish Ministry of Health. In reality, this means
that "he Ministry keeps a close watch on it in order to
neutralize 'expensive' healthcare technologies, as their adoption
results in requests for extra funding from the regions."
France. In France, health care is a statutory
right enshrined in the Constitution of the Fifth Republic. Unlike
in Denmark or the United Kingdom, however, French health care is
financed mainly by social insurance and delivered by a mixture of
public and private providers. While two-thirds of French hospitals
are state-owned, one-third are private, with half of the latter
group being not-for-profit.
There have been various attempts in recent years to extend
government control of health care costs. In 1991, the French
government extended its Health Map system by which it controls the
capital construction of all hospitals as well as their budgets, the
purchase of medical equipment, the rates charged by private
hospitals, the number of pharmacies per head, and even the price of
drugs.
In 2005, the government went a stage further with the
establishment of a centralized High Health Authority. While this
body has had only a limited impact–and France continues to enjoy a
comparatively higher diffusion rate for new technologies than is
found in many other countries in Europe–it is nevertheless
designed to stipulate the benefits of medicines and determine their
price-reimbursement levels. As such, it is set to raise the focus
on cost-containment and bring its decision-making under closer
state control.
Germany. As in France, health care in Germany is
financed primarily by social insurance and provided by a mixture of
public and private providers. While all services are contracted
instead of being provided directly by the government, more than 10
percent of Germans opt for full private medical insurance.
Providing a potent source of exit from the state, the regulated
private sector puts pressure on the government to ensure that the
sectoral differences in service do not become so wide that
ever-larger numbers of young, high-income consumers defect by going
private and delegitimizing a central pillar of the Bismarckian
philosophy.
While the pressure to maintain some semblance of parity with the
private sector meant that state spending rose dramatically for many
years after the introduction of a formal reference pricing system
in 1989, the strategic objective of the German Ministry of Health
has been to reduce supply, particularly through the use ofpublished
positive and negative lists concerning medicines and treatments.
Through these lists, pressure is applied to the statutory sick
funds to control costs.
It is in this context that health technology assessment has
played an ever-greater role in German health policy since the
1990s. In 1990, the Office of Technology Assessment at the German
Parliament (TAB) was established, and in 2004, the government set
up the Institute for Quality and Economic Efficiency in the
Healthcare Sector (IQWiG).
Tasked with the central goal of efficiency, IQWiG investigates
and stipulates which therapeutic and diagnostic services are
appropriate. Disseminating its pronouncements to
various self-governing bodies, its information is used concerning
the coverage of technologies in the benefits catalogue. With such
ventures being funded primarily by the German Ministry for Health
and Social Affairs, assessment bodies can refuse a hospital's claim
for reimbursement for the unauthorized use of new technology.
Lessons for American Policymakers
There is a pervasive European mythology: a widespread belief
that American health care is rooted in the free market. In reality,
much of American health care is a highly planned, regulated, and
government-funded system. Through major entitlement and welfare
programs such as Medicare and Medicaid, which contribute to rapidly
growing American health care costs, government takes a historically
higher proportion of gross domestic product than does even the
British NHS. Moreover, by virtue of the structure and financing of
private-sector health insurance, there is little consumer control
over health care dollars.
Nonetheless, the United States is not only a major consumer of
health care services, but also the world's largest producer of
medical technology. Investment in new medical technology is
comparatively high, as is its rate of diffusion: "This is
demonstrated by cross-national examinations of the comparative
availability of selected medical technologies such as radiation
therapy and open-heart surgery. Measured in units per million, the
United States experiences levels of availability up to three times
greater than in Canada and Germany."
During the presidential campaign, Barack Obama proposed an
Institute for Comparative Effectiveness that would make formal
recommendations on medical technologies, devices, and drugs. In
Congress, champions of comprehensive overhaul of U.S. health care
favor policies that would explicitly accelerate America's
trajectory downward toward a European-style medical
interventionism.
Fearing the impact of the rising costs of Medicare, Medicaid,
and the highly regulated arrangements of the private insurance
sector, many American legislators and other top policymakers are
becoming attracted to the idea of a body that would make top-down
pronouncements on the cost-effectiveness of new medical
technologies. The idea of a statutorily created agency charged with
system-wide cost containment and rationing of medical services and
technologies is becoming surprisingly fashionable in Washington
policy circles.
The implications of this trend are alarming for U.S. citizens,
particularly when one considers that the technology a society uses
reflects the wider and underlying incentive structures it adopts
for using it: "An incentive structure that encourages providers to
trade off the costs and benefits of health care gives providers
little incentive to use expensive technologies and thus researchers
will have little incentive to create it."
In the long term, a statist, centralized control of medical
technology offers little if any regulatory benefit. Through its own
logic, it not only stifles innovation, but also, in doing so, ends
up precluding those very inventions that could turn out to be of
immeasurable benefit to individuals and to society in general.
If comparative effectiveness and health technology assessment
especially are to be useful, they must be generated primarily by
the private sector on a competitive and non-coercive basis. In
avoiding the imposition of a uniformity of rules that comes with
government intervention, physicians and other medical professionals
would and should remain free to pick and choose from the best
practices and professional insights into the treatment of medical
conditions as they see fit (with, of course, the informed consent
of their patients).
It is only by returning health care to a genuinely
patient-centered and consumer-driven health care marketplace that
information, innovation, and best practice will permeate the
complex array of health care arrangements in both the public and
the private sectors. It is only through open competition and the
economic discipline of the free market that real progress and
productivity can be secured.
Therefore, in framing a policy on comparative effectiveness,
America's policymakers should be governed by four principles:
- They should reject the statutory creation of a board,
council, or institute that would centralize government control of
patient access to drugs, devices, medical technologies, treatments,
or procedures. This is especially the case if such an agency
were to have the power to override the considered judgment of
competing professional expertise, especially the professional
judgment of a patient's attending physician. - Comparative effectiveness research and health technology
assessments should be undertaken primarily by the private
sector. While government can contribute to research efforts and
promote the widespread availability of the best information, it
must not exercise monopoly power over the conduct of research
itself or the distribution of information. - Comparative effectiveness research should be
patient-centered and supportive of quality and value, not focused
simply on cost-containment. In this respect, it should foster
scientific advances, health information technology, and the
emerging science of personalized medicine. - Comparative effectiveness research must move beyond
randomized clinical trials and embrace practical clinical
trials. It should include observational data, and its
methodologies should fully address issues such as the validity and
applicability of findings.
Conclusion
As is clear from the British experience and other international
examples, a comparative effectiveness strategy that relies on
central planning and coercion would not only be counterproductive
in the long run–because it would undermine the incentives for
medical innovation–but would also lead to the imposition of cost
constraints that would worsen patients' medical conditions and
damage the quality of their lives.
Helen Evans, Ph.D., is a citizen of
the United Kingdom. A registered general nurse, she is the Director
of Nurses for Reform and a Health Fellow with the Adam Smith
Institute of London, England.
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Health Care: WH Awaits Insurance Rules
• “Health and Human Services Secretary Kathleen Sebelius could find herself pitted between top Democrats on Capitol Hill and state insurance commissioners over a key section of the health care overhaul,” Politico reports. “Sebelius is waiting for the National Association of Insurance Commissioners to suggest rules surrounding how much insurance companies must spend on medical costs versus administrative expenses or profits. The report, expected in weeks, isn't likely to be as strict on insurers as top Democrats have hoped.”
• “The Obama administration is rewriting new rules on medical privacy after an outpouring of criticism from consumer groups and members of Congress who say the rules do not adequately protect the rights of patients,” the New York Times reports. “The rules specify when doctors, hospitals and insurers must tell patients about the improper use or disclosure of information in their medical records. Such breaches appear to have become more frequent, with the growing use of health information technology, social media and the Internet.”
• “A key member of Congress plans to send a letter to federal regulators” today “seeking a detailed explanation of what they knew about the activities of an Iowa egg producer at the center of a salmonella outbreak and massive egg recall,” the Washington Post reports. “Rep. Rosa DeLauro (D-Conn.) plans to ask the Food and Drug Administration and Agriculture Department about Austin 'Jack' DeCoster, who owns Wright County Egg.”
• “Insurance agents and brokers, afraid of being rendered irrelevant in the post-health reform world of simplified insurance shopping, are fighting for their very survival,” The Hill reports. “The agents want lawmakers' and regulators' support in getting the Obama administration to recognize their role in the federal insurance Web portal, which lets consumers compare coverage options online.”
by Lisa Gualtieri, PhD, ScM
Stories can enhance health websites because they resonate with health information seekers, who find support and encouragement from the experiences of others like them. Two excellent examples are Weight Watchers’ Success Stories and Livestrong.org’s Survivorship Stories. Both sites include extensive libraries of well-written stories about people’s experiences losing weight and surviving cancer, respectively.
Because of the effectiveness of stories in health websites like these, I challenge my Online Consumer Health students to consider how the inclusion of stories can enhance the websites they design in class. In one assignment, they first review the purpose, length, transparency of authorship, writing style, and perceived accuracy of stories on health websites. Then they either write or reuse stories from other websites for their own sites.
In my constant search for examples to use in class, I came across the stories in RediscoverYourGo. I contacted the developer to learn about the planning and design of the website, particularly how the decision was made to use stories.
I spoke with Simon Lee, CEO of Lee-Stafford on February 8, 2010. RediscoverYourGo was developed for a medical device company, Smith & Nephew, that manufactures parts for hip and knee implants. On the home page, “stories” is one of 4 tabs on the left and 3 links to stories are featured on the lower right next to “Learn from real patients who have rediscovered what it means to live pain free.” The “stories” tab leads to a list of the replacement products headed by, “Real people who have rediscovered their go.”
Each replacement product has story snippets from people who have had surgery to implant that product. The story snippets are brief, first-person quotes and they include the name (generally the first name and last initial but in some cases the full name), city, and product, illustrated by a photograph. Rather than use a headshot, many show active poses and look like they were taken informally, not by a professional photographer (in contrast to the posed “after” pictures on Weight Watchers). There is some duplication, with some people appearing in more than one category, presumably because the person has used multiple products. The first person quotes were extracted from a letter or interview with, as Simon said, “100% real patients.”
Selecting a snippet leads to a longer story in the third person about the person’s experience with pain, learning about and contacting the surgeon, undergoing the surgery, recovering, and developing a post-surgery active lifestyle. The header includes more about the person, including occupation, a larger version of the snippet photograph, and a picture of the replacement product. Many of the stories identify the storyteller’s age, and the photographs indicate age as well. Stories are more likely to resonate with someone who identifies with the storyteller, which, in this case, might be because of replacement product, age, or recreational activity. Weight Watchers facilitates this by sorting stories by gender, age, or total weight loss and inviting a viewer to ”Read about someone like you.”
The use of stories is “a toe in the water” to create an online community for patients with Smith & Nephew products. What lay behind the use of stories, Simon told me, was the desire to create a “patient ambassador network” to capitalize on patient stories. Often patients with debilitating pain became advocates for the surgeon who “fixed” their problem: they wrote letters thanking the doctors who performed their replacement surgery for giving them their life back and were eager to discuss their outcomes with others.
Simon believes the more open use of social media or forums was not possible because of concerns about monitoring, disclosures and privacy, a concern shared by all the major orthopedic and spine device companies. Highlighting patient experiences on a website seemed the best alternative.
The overall website design goal was to modernize the brand and create more youthful and non-surgical-looking site as befitting one of the big growth areas: patients 45+. Previously, the primary target audience was 65+. The focus on the new demographic is because a growing number of younger people are seeking partial replacements. The potential exists that they will then become loyal customers to the brand and their surgeon.
Simon believes that healthcare is local and that decisions to choose care are “based on who can treat me and where can I be treated.” Furthermore he believes that “educated patients are happy patients and happy patients are advocates for the doctor who ‘healed’ them.”
Lisa Gualtieri is Adjunct Clinical Professor in the Health Communication Program at Tufts University School of Medicine and blogs at her self-titled site, Lisa Neal Gualtieri.
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Almost every day someone calls me and I have to tell them that I can’t help them, that the health care debate issue isn’t resolved and that they will have to choose between losing their health and losing their money.
I have the privilege of being the person who gets to tell hundreds of people each year that they don’t qualify for medical insurance. That the national healthcare debate on kids and adults hasn’t reached a resolution that will help them meet their basic needs for medical care.
I don’t know if the Barak Obama health care plan or if Hilary Clinton’s health care plan is better. I don’t know if president bush’s plan on health care is optimal. I don’t know if when the president vetos a health care bill he is right or wrong. I just know when grown people start crying after they hear how the health care debate has failed them something is horribly wrong with the way we handle this issue in America.
Why we need healthcare reform- reason 1
It fails us when we need it most!
I get calls from people who have worked all of their lives and who were always covered by their job’s medical plan. At some point they developed a disease or had an accident that ended their ability to earn a living. Shortly after this event they lost their job. They were offered COBRA, but COBRA usually last 18 months. After this 18 month period, they are often uninsurable for all but the outrageously expensive guaranteed issue plans offered by the government. These plans often cost several time what a standard plan costs and the standard plans are not cheap.
Why we need healthcare reform- reason 2
The Debate is about who pays for it!
There doesn’t seem to be any thought to ways to reduce the frequency of doctor’s visits. The is nothing done to promote the ideas of eating and living better to reduce the actual costs, just ways to shift the burden of the costs to different people. Frankly, I don’t want the government to tell me that I should stop eating candy nor do I want Big Brother forcing me to do calisthenics every morning. However, I do believe that more should be done to reduce our need for health care and not just change the person or persons who pay for it. I hope that this gets added to the national debate.
Something needs to be done. Universal? Egalitarian? Mandatory? Paid for by consumers? Paid for by taxes? I don’t know. But there should be an answer in a country with the resources that the United States of America has.
Individuals, who have obeyed our laws should be able to find reasonably priced health care regardless of any pre existing condition. The universal healthcare debate which seemed to have peaked in the Hillary Clinton 1993 health care plan, needs to reach a level where we get motivated enough to do something and to fix this pressing problem.
Almost every day someone calls me and I have to tell them that I can’t help them, that the health care debate issue isn’t resolved and that they will have to choose between losing their health and losing their money.
I have the privilege of being the person who gets to tell hundreds of people each year that they don’t qualify for medical insurance. That the national healthcare debate on kids and adults hasn’t reached a resolution that will help them meet their basic needs for medical care.
I don’t know if the Barak Obama health care plan or if Hilary Clinton’s health care plan is better. I don’t know if president bush’s plan on health care is optimal. I don’t know if when the president vetos a health care bill he is right or wrong. I just know when grown people start crying after they hear how the health care debate has failed them something is horribly wrong with the way we handle this issue in America.
Why we need healthcare reform- reason 1
It fails us when we need it most!
I get calls from people who have worked all of their lives and who were always covered by their job’s medical plan. At some point they developed a disease or had an accident that ended their ability to earn a living. Shortly after this event they lost their job. They were offered COBRA, but COBRA usually last 18 months. After this 18 month period, they are often uninsurable for all but the outrageously expensive guaranteed issue plans offered by the government. These plans often cost several time what a standard plan costs and the standard plans are not cheap.
Why we need healthcare reform- reason 2
The Debate is about who pays for it!
There doesn’t seem to be any thought to ways to reduce the frequency of doctor’s visits. The is nothing done to promote the ideas of eating and living better to reduce the actual costs, just ways to shift the burden of the costs to different people. Frankly, I don’t want the government to tell me that I should stop eating candy nor do I want Big Brother forcing me to do calisthenics every morning. However, I do believe that more should be done to reduce our need for health care and not just change the person or persons who pay for it. I hope that this gets added to the national debate.
Something needs to be done. Universal? Egalitarian? Mandatory? Paid for by consumers? Paid for by taxes? I don’t know. But there should be an answer in a country with the resources that the United States of America has.
Individuals, who have obeyed our laws should be able to find reasonably priced health care regardless of any pre existing condition. The universal healthcare debate which seemed to have peaked in the Hillary Clinton 1993 health care plan, needs to reach a level where we get motivated enough to do something and to fix this pressing problem.
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Delegate Donna Christensen on Monday morning convened a new commission within the Congressional Black Caucus' Health Braintrust focused on health disparities between racial and ethnic groups.
“Our purpose is to ensure that the provisions that serve to eliminate health disparities and foster health equity are implemented to the fullest extent,” said Christensen in a statement.
All the members of the new commission, the Health Equity Leadership Commission, have substantive expertise in one or more areas of public health, health policy and health equity, according to a statement from Christensen's office.
According to Christensen, who serves as chair, the commission was established not only to ensure that pertinent health care reform information is communicated to those in and serving racial and ethnic minority communities, but also to serve as an expert resource to the Obama administration and the U.S. Department of Health and Human Services as the various provisions in this year's federal health reform act are planned and implemented.
“While the enactment of the Patient Protection and Affordable Care Act (PPACA) marked a historic day in this nation, a day that very few believed would ever occur, the real work of ensuring that meaningful health care reform is achieved is only beginning,” said Christensen. “This is particularly true of the numerous health equity provisions that are included in the new law.”
Aug. 18, 2010 — Children with the eye condition strabismus, often called cross-eyed or squint, are less likely to be accepted by their peers, according to a new study.
“Negative attitudes appear to emerge at approximately 6 years and increase with age,” write the Swiss researchers in the report of their study, published online in the British Journal of Ophthalmology.
In most cases, ''parents really should not wait longer than age 5 for surgery,” researcher Daniel Stephane Mojon, MD, head of the department of strabismology and neuro-ophthalmology at Kantonsspital, St. Gallen, Switzerland, tells WebMD.
A U.S.-based expert says the study results are not surprising, but that there is good news. “Fortunately, strabismus is often a treatable condition,” says James Plotnik, MD, a pediatric ophthalmologist in Scottsdale, Ariz., and a clinical correspondent for the American Academy of Ophthalmology, who reviewed the study for WebMD.
The study finding ''demonstrates another potential benefit of early intervention to align the eyes,” Plotnik says.
Children With Strabismus: A Closer Look
Although research has found that adults with strabismus can be negatively affected psychologically, fewer studies have looked at children with the condition and how they are affected socially, according to the research team from the University of St. Gallen, University of Bern, and Kantonsspital.
Strabismus is common, Plotnik says, occurring in about 4% of children in the U.S. and sometimes also occurring later in life.
Crossed eyes is the most common form, Mojon says, although strabismus can describe eyes that turn outward, inward, up, or down.
Experts don't know the cause, but sometimes the condition is related to problems with the muscles that control eye movement.
The Swiss researchers gathered 118 children, ages 3 to 12, with an average age of 7, and showed them photographs of six identical twin pairs, half boys and half girls. The photos were digitally altered so that one child had misaligned eyes and a darker or lighter shirt.
The researchers asked the children which of the two ''twins'' they would invite to their birthday party. The children were asked to make a choice four different times, so that meant they could select the faces of up to four children with misaligned eyes.
How Strabismus Affects Children: Results
The children who were aged 6 and older were much less likely to invite a child with strabismus to their party.
Although only one of the 31 children aged 4 to 6 didn't select a single child with strabismus, 18 of the 48 children aged 6 to 8 did not.
None of the children aged 6 to 8 chose a child with strabismus all four times, but three of the children aged 4 to 6 did.
When asked if they noticed anything in particular about the twins, the percentage of kids who made specific comments about the eyes increased with age:
- 19% of kids aged 4 to 6 commented on eye alignment without being asked to pay attention to eyes.
- 48% of kids aged 6 to 8 commented on the eyes without being asked to notice eyes.
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August 15th, 2010 admin
Mental Health Insurance
The mental health insurance benefits have changed a lot in the past few years. It is very vital that you understand the mental health care coverage. As you probably know, mental health is a very broad topic and at the time of looking for a mental health insurance, you should make sure that the policy covers a variety of mental disorders. I am sure you are aware that mental health disorders are of different kinds and generally, mental health insurance will offer coverage for problems like behavior disorders, depression, anxiety and substance abuse. Many people can obtain insurance through their jobs but unfortunate, it may not include mental health issues.
The insurance coverage will depend on what the provider or the insurance agency is offering. Generally, the agencies cover issues like depression, anxiety, social phobias and relationship problems. On the other hand, the coverage will not include aromatherapy or weight loss. Depending on the insurance plan that you have taken out, you may be allowed to see the therapist of your preference. When it comes to choosing a mental health insurance policy, it is important for you to first find out whether you will be free to choose your own therapist when you get the policy. It is always advised that you try to check out as many insurance companies as you can, before you decide to opt for one company. This way you will be able to find out which agency is offering you maximum benefits. Just like any other things, it is necessary that you carry out research before getting the insurance.
If truth be told, mental health insurance has not been around for a long time because about a decade ago, the insurance companies would pay nothing or little coverage for mental health problems. The best way to ensure that you are getting the best deal is to shop around and look for the various kinds of plans offered by different insurance agencies. You can check out an insurance comparison website and compare the quotes from the leading insurance companies. There are certain points that you should keep in mind when you are looking for an insurance company:
Does the policy restrict the number of visits to the therapist? Does it include a lifetime cap? Does it include a separate deductible each year for the mental health services? Does the policy mention the names of the hospitals or therapists that you will have to choose from? Will you need to pay the fee yourself if you choose a therapist not listed by the insurance company?
Simply visit /www.cartografiamental.com for more detailed information regarding mental health insurance.
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The oil spill along the United States Gulf Coast poses health risks to volunteers, fishermen, clean-up workers and members of coastal communities, according to a new commentary by UCSF researchers who spent time in the region and are among the first to look into health problems caused by the oil spill. The good news, the authors say, is that one of the risk factors, coastal air quality, is improving now that the oil leak has been stopped.
The commentary will be published online August 16th and in the September 8, 2010 issue of the Journal of the American Medical Association.
The goal of the article is to inform physicians and coastal communities about the immediate and long-term health risks posed by toxic vapors, oil slicks, tar balls and contaminated seafood. The authors hope to encourage community members to protect themselves and seek treatment if symptoms from oil contamination occur.
“The oil spill in the Gulf of Mexico is well known as an ecological disaster, but what is less known is the risk to human health caused by oil contamination. We want to reach the volunteers, clean-up workers, fishermen, medical specialists and community members with practical information about the impact to their health from these chemicals. With correct information, we hope they can protect themselves and seek treatment if they don’t feel well,” said Gina Solomon, MD, MPH, senior author, director of UCSF’s Occupational and Environmental Medicine Residency and Fellowship Program and senior scientist with the Natural Resources Defense Council (NRDC) in San Francisco.
Air quality, skin irritation, mental health and seafood safety are the primary areas of short and long term health concerns, according to the authors. The article cites health information collected from previous oil spills in Alaska, Spain, Korea and Wales, which report an increase in health effects such as respiratory problems, DNA alterations, anxiety, depression, post-traumatic stress disorder, psychological stress and self-reported neurological impairment in workers and local residents.
In the early months of the Gulf oil spill, more than 300 individuals, most of whom were cleanup workers, sought medical attention for headaches, dizziness, nausea, chest pain, vomiting, cough and respiratory distress that might be consistent with chemical exposure, according to data collected by the Louisiana Department of Health and Hospitals.
“Louisiana is making an effort to track health complaints,” said Solomon. “But it is important to remember that these 300 reported cases are only from one state and only within a few months. The Gulf Coast is a large region with many coastal communities, and it is imperative that we do whatever we can to help everyone impacted by this disaster.”
The risk to air quality comes partly from volatile organic compounds that evaporate within hours after oil makes contact with water. These chemical compounds can cause respiratory irritation, headaches, and nausea. Other compounds released by the oil or by the chemicals used to disperse the oil include chemicals that can cause skin irritation, respiratory problems and damage to the central nervous system.
“Clinicians should be aware of and look for evidence of toxicity from exposures to oil and related chemicals,” study co-author Sarah Janssen, MD, PhD, MPH, assistant clinical professor at UCSF and senior scientist with the NRDC. “Symptomatic patients should be asked about occupation and location of residence, and the physical examination should focus on the skin, respiratory tract, and neurological system.”
To protect coastal community members from exposure to chemicals caused by the oil spill or its dispersants, the researchers advise the following measures:
- Workers may need protective equipment such as hats, gloves, boots, coveralls, safety goggles, and even respirators in some areas;
- Workers need to take breaks and drink ample fluids to prevent heat-related illness;
- Avoid skin contact with tar or oil on beaches, marshland or in the water;
- Do not fish in areas of known oil contamination or where there is visible oil;
- Do not eat seafood that smells oily or strange;
- If there is a strong smell of oil outside and it makes you feel ill, go inside and adjust the air conditioner to recirculate air;
- If you are feeling persistently ill, seek medical attention so your symptoms can be assessed and reported.
UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. For further information, visit www.ucsf.edu.
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According to the Substance Abuse and Mental Health Services Administration, an estimated two-thirds of the young people who need mental health services aren’t getting them. The time is now for a career in child and adolescent mental health.
Mental Health Career Profile
Establish and maintain interpersonal relationships, discover private, and very often hidden, information, and then use that information to potentially save someone’s life. If you believe a meaningful career is about more than just a paycheck, mental health could your profession. With a growing population and the identification of new disorders, the field is ripe for growth and discovery.
Child and adolescent mental health services typically focus on a variety of mental, emotional, and substance abuse issues kids experience daily. This may mean working with patients as individuals or in group settings in order to find answers to developmental difficulties. Working environments may include hospitals, clinics, schools, as well as mental health facilities.
A Career at the Competitive Edge
Why mental services? In a word, diversity. One of the primary benefits of a career in this profession is that you’re typically not restricted to a predictable track. There are multi-level tiers that cater to a variety of interests and education levels. Many of the niches overlap, which can allow you to explore your preferences. A few of your options include:
• psychiatry occupational therapy
• clinical psychology
• psychiatric nursing
• social services
• psychotherapy
• language development
Flexibility is another key benefit. A surprising percentage of mental health professionals are self-employed, working within their own established practice or as a freelance consultant. Because mental health is such an in-demand profession, graduates may find that they can create their own schedules, deciding when and how much to work based on their own professional and personal obligations.
Mental Health in the Numbers
When most people think of mental health, the psychologist usually comes immediately to mind. And it can be a good place to start when looking at the growth potential in the field of child and adolescent mental health. The Bureau of Labor Statistics reports that psychologists alone held 166,000 positions in 2006. And employment of psychologists projected to increase by 15 percent through 2016–that’s faster than the national average. Also, psychologists working in elementary and secondary schools enjoyed one of the higher annual mean salary levels at $66,040.
To Follow This Career Path
While all professionals in the mental health field typically possess a bachelor’s degree in a pertinent subject, students wishing to be competitive for the top jobs should pursue a specialist’s or doctoral degree in psychiatry, psychology, or counseling. For example, if you have your sights set on serving in an educational setting, a specialist (EdS) degree in school psychology traditionally requires 3 years of full-time graduate study plus a 1-year full-time internship.
The requirements for potential psychologists are usually more stringent. Geri Fox, Director of Psychiatry Undergraduate Medical Education with the University of Illinois at Chicago, encourages board certification by completing two years of child and adolescent psychiatry training in addition to earning board certification in general psychiatry.
UPDATED CHART SHOWS OBAMACARE’S BEWILDERING COMPLEXITY
Washington, D.C. – Four months after U.S. House Speaker Nancy Pelosi famously declared “We have to pass the bill so you can find out what’s in it,”a congressional panel has released the first chart illustrating the 2,801 page health care law President Obama signed into law in March.
Developed by the Joint Economic Committee minority, led by U.S Senator Sam Brownback of Kansas and Rep. Kevin Brady of Texas, the detailed organization chart displays a bewildering array of new government agencies, regulations and mandates.
“For Americans, as well as Congressional Democrats who didn’t bother to read the bill, this first look at the final health care law confirms what many fear, that reform morphed into a monstrosity of new bureaucracies, mandates, taxes and rationing that will drive up health care costs, hurt seniors and force our most intimate health care choices into the hands of Washington bureaucrats,”said Brady, the committee’s senior House Republican. “If this is what passes for health care reform in America, then God help us all.”
Brownback, the committee’s ranking member, added, “This updated chart illustrates the overwhelming expansion of government control over health choices and the bewildering complexity facing everyone affected by this law. It doesn’t take long to see how the recently signed health care bill causes a hugely expensive and explosive expansion of federal control over health care. Personal choices that should be between a doctor and a patient will quickly be strangled in a never ending web of bureaucracy.”
Senate Steering Committee Chairman Jim DeMint (R-South Carolina) called Obamacare “a bureaucratic nightmare. The Democrats’ takeover of health care creates a byzantine network of 159 new federal programs and bureaucracies to make decisions that should be between just the patient and their doctor. It should concern everyone that at the center of this regulatory web is the new CMS chief, Donald Berwick, who has championed rationing and European socialized medicine. Americans were rightly outraged that this big government bill was rushed through Congress before anyone read or fully understood the bill’s consequences. Republicans will fight to repeal this reckless takeover and to ensure health care freedom to American families.”
In addition to capturing the massive expansion of government and the overwhelming complexity of new regulations and taxes, the chart portrays:
-
*
$569 billion in higher taxes;
*
$529 billion in cuts to Medicare;
*
swelling of the ranks of Medicaid by 16 million;
*
17 major insurance mandates; and
*
the creation of two new bureaucracies with powers to impose future rationing: the Patient-Centered Outcomes Research Institute and the Independent Payments Advisory Board.
Brady admits committee analysts could not fit the entire health care bill on one chart. “This portrays only about one-third of the complexity of the final bill. It’s actually worse than this.”
Source: Congressman Kevin Brady’s website
SideBear: What you are seeing here is an unbelievable massive growth of BIG GOVERNMENT that ObamaCare will create.
It is a Frankenstein monster on steroids.
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ANNAPOLIS, Md. — An economic model estimates Maryland could save about $829 million on health care costs between fiscal year 2011 and 2020 under federal health care reform.
The model is part of a report scheduled to be released Monday by Maryland's Health Care Reform Coordinating Council.
The savings, however, last only until the end of the decade, when the federal law shifts a greater share of financial responsibility for Medicaid expansion to the states.
While the report emphasizes that current and future projections are fluid, it cautions that the state must stay committed to reducing overall health care costs.
That's because Maryland is projected to spend $46 million more in fiscal year 2020 as a result of health care reform than it would without it.STATEN ISLAND, N.Y. — Staten Island's health care system may need fixing, but that doesn't mean that borough residents can't take steps to improve their well-being.
That's the goal behind the second annual Staten Island Health and Wellness Expo, which will be held on Sept. 28 at the Hilton Garden Inn in Bloomfield.
“Staten Islanders need to take care of their own health and wellness,” said City Councilman James Oddo (R-Mid-Island/Brooklyn), who is a lead sponsor of the free, day-long event along with the Northfield Bank Foundation.
The conference, titled “Plan To Be Healthy” will focus on wellness as the first step toward leading a healthy lifestyle. It will feature classes and seminars on healthy eating, exercise regimens, stress management and other opportunities for healthy living.
Islanders can also get free mammograms and hearing and diabetes tests at the expo.
“We can't control the health care system,” said Oddo. “What we can control is our own behaviors.”
Oddo and the Northfield Foundation are each allocating $50,000 to help pay for the expo. Organizers held a press conference last week to announce the event.
“We're happy that everyone is cooperating,” said Diane Senerchia, executive director of the bank foundation. “They are offering so many free services. It's important.”
Susan Lamberti, chair of the foundation, will serve as a committee member for the expo.
The College of Staten Island (CSI) will serve as a sponsor for the event.
“Health, wellness and access to health care are severe problems and challenges for Staten Island,” said Dr. Tomas Morales, president of CSI, who is an ambassador for the expo.
He pointed to the higher rates of smoking, obesity and diabetes found on the Island.
“All are major concerns,” Morales said.
CSI will sponsor a presentation called “Finding Balance in Your Life,” and will join with Wagner College and St. John's University to present another seminar, “College Health, Health for a Lifetime,” aimed at college-age Islanders.
A number of other borough organizations and businesses, including the Staten Island Economic Development Corp., will also have leading roles at the expo.
For more information, go to http://www.healthysi.com.
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