Pay Health Care Aides to Jump-Start the Economy

Pay Health Care Aides to Jump-Start the Economy is a guest post by David K. Cundiff, MD

When my elderly and disabled father and stepmother required long-term care, I had the resources to hire compassionate and competent caregivers to keep them in their own home until they died. Considering the wonderful care they gave, they didn’t cost very much ($4,500 per month for 24 hour-7 day care, i.e., about $6.25 per hour). Most Americans are not as fortunate as my parents and me in their options concerning long term care.

Of about 16 million disabled Americans requiring long-term care, only approximately 1.6 million live in nursing homes. The rest remain at home receiving varying amounts of personal care (e.g., bathing, dressing, and preparing meals) delivered by about 835,000 professional home health aides, like those I employed for my parents, and unpaid family members and friends. Professional home care aides, primarily low income women, are themselves unprotected by basic labor standards despite efforts to do so in Congress. Consequently, low pay (averaging $9.62 in 2007), long hours, and high turnover undermine the quality of care, as noted by a recent New York Times editorial.

According to survey data compiled by “Strength for Caring,” an organization that advocates for caregivers, approximately 46 million Americans are providing care to an adult relative or friend and more than 138 million Americans believe they will need to provide care to someone in the future. Caregivers spend 21 hours per week on assisting their loved ones. Caregivers suffer high stress, increased rates of anxiety and depression, and major financial and personal sacrifices. Based on this analysis and many other studies, advocates for long-term care have repeatedly called for the government to provide financial relief by tax credits or otherwise for caregivers of non-institutionalized disabled people. Congress has not responded to these pleas for caregiver relief based on compassion and economic justice.

Now that the economy is in decline with massive job losses, consider the economic effect of providing well earned money to the 46 million personal care providers (31 million full-time equivalents). Paying minimum wages to family and friends of the disabled for their caretaking time ($7.25 per hour beginning July 2009) would cost about $360 billion per year (46 million health aides x 21 hours per week average per caregiver x 52 weeks/year x $7.25 per hour for wages plus benefits = $364 billion).

A successful model program exists. For people with Medicaid insurance, a pilot project of giving disabled people money to pay for their own caregivers has been a huge success. Investigators at Mathematica Policy Research, Inc. found that, compared with services from traditional home care agencies, Medicaid’s “Cash and Counseling” program gave disabled people and their caregivers improved quality of life and resulted in less use of nursing homes.

These 31 million full-time equivalent paid jobs could be created immediately. This $360 billion spread broadly (average yearly income: about $7,800 for 46 million people) would be what the doctor ordered to immediately help counteract massive job losses throughout most economic sectors. Much of the money would be immediately returned to taxpayers, because paying these health care workers would mean they require less public assistance. The collateral economic benefit of the money these workers would spend for necessities would have an infinitely greater multiplier effect in creating more jobs than lavishing more billions on banks or enacting the $800+ billion proposed stimulus bill. It would address Republican concerns that the stimulus create jobs immediately and Democrat priorities that the money go to help the poor.

You might say, “Why should public money pay for family members and friends to care for disabled people in their private residences?” If those 46 million unpaid caregivers quit and their 14 million disabled loved ones went into nursing homes, society’s cost would be at least $1.3 trillion (14 million non-institutionalized disabled people x $95,000 per year average nursing home cost in 2010 = $1.33 trillion).

Paying home care providers would also provide financial incentives to move some of the 1.6 million Americans living in nursing homes back home to their families and friends. For each nursing home resident moved back to home, about $69,000 per year would be saved ($95,000 per year on average for nursing home care in 2010 – $26,000 for 69 hours per week of home care on average = $69,000).

Over the long term, funds for home care aides should not come from more borrowing and increasing the national debt but from true comprehensive health care reform. No student of health care policy doubts that the $2.7 trillion that Americans will pay for health care in 2010 includes massive waste. Real health care reform should shift enough wasted money in our highly dysfunctional medical system to provide ongoing funding of currently unpaid home caregivers.

David Cundiff is a retired internist and hospice physician who lives in LA County.  He is now working on a book titled Doctor Managed Care.

22 thoughts on “Pay Health Care Aides to Jump-Start the Economy

  1. It’s a big problem that health care aides aren’t paid well. Some direct care workers don’t even have health care insurance for themselves! Health care aides are so important and with our aging population will be in high demand (the US Bureau of Labor Statistics expects this field to grow by as much as 28% from 2006 – 2016…more than the average for most occupations), yet the pay is low and there isn’t much room for advancement. The opportunity employment-wise is that there isn’t much education required to become a health care aide and one can get their foot in the door to the health care field this way while getting additional schooling to advance their career. However, considering the work they do, better pay really should be in order. There are many trades that don’t require much education, but most are not paid as little as home health care aides!

  2. I couldn’t agree more!
    We need a public works program much more massive than that of the New Deal, and it has to be much more weighted toward health care, education and other services. A big reason we’re in an economic crisis is we’re TOO productive: too many auto plants making cars no-one can afford to buy. So the surplus went to financial ponzi schemes instead of shortening the workweek and re-employing people in the sectors named above.
    Andrew Pollack
    Analyst, Maimonides Med Ctr

  3. With all due respect, this is one of the most ill conceived healthcare related ideas I’ve ever heard. I think any economist will tell you that $360 billion PER YEAR plus inflation adjustments in the future is cost prohibitive when we already have a huge federal budget deficit even without counting the cost of the stimulus package and the financial system rescue effort. The stimulus package, by the way, is a supposedly one time expenditure intended to jump start the economy, not an annual recurring expense while much of the money spent on helping the banks will ultimately be recovered by taxpayers.
    People who care for loved ones are not likely to quit despite the emotional and financial costs because they are doing it out of a combination of love and duty. Even if they did quit, we don’t have the physical and human resources to care for their loved ones in nursing homes, assisted living facilities or in their own homes with help from home healthcare workers.
    It would also likely be administratively impossible to reward family members with either tax credits or actual pay to care for their loved ones. How would we verify the hours they worked? Even people who live with or near loved ones who don’t need any help could game the system by claiming that they spent 10 or 20 hours a week or whatever providing care. And, as I said above, we cannot afford to pay for the legitimate care being provided in any case.
    It’s no accident that long term care is only covered for the indigent by the means tested Medicaid program and, to a very limited extent, by Medicare for patients needing rehabilitation or short term care after being discharged from a hospital. If long term care were ever covered fully by Medicare, people would come forward literally by the millions to claim benefits. Universal long term care coverage is unaffordable by any measure, and that’s why it will probably never happen.

  4. I have to agree with Barry. The idea is nice in theory, but I think that the implementation would be prone to abuse.
    The idea is akin to paying parents to stay at home and take care of their dependent infant children. Why should old age be a compensable event? Who is going to determine which 65 year olds’ families get paid for 24 hour care versus those whose family members get paid while the “patients” are out on the ski slopes?
    In effect, this program would take centralized care at a nursing home and decentralize it, which would cause redundancy of services being provided. Imagine decentralizing hospital care so that patients could stay at home.
    The risks of this idea are much greater than the perceived benefits.

  5. This may not be a bad idea, Maggie. It could be something like the WPA Project (Works Progress Administration) during the first great depression. It employed millions of people and affected most every locality in the United States. The various programs of the WPA added up to the largest employment base in the country. Anyone who needed a job could become eligible for most of its jobs.
    I know it gave one of my grandfathers a job. And each and every time I would travel up to our famous Reading Pagoda on Skyline Drive, I would be reminded of the project he participated in. All of the beautiful stone barriers along the skyline drive were crafted by dozens of workers like my grandfather, out-of-work citizens wanting to work but there were no jobs. Almost every community in America has some park, bridge, road project or school constructed by the agency.

  6. Rick, Lynn, Andrew, Barry, White Coat
    Andrew–
    Thanks very much for the comment. You write: “A big reason we’re in an economic crisis is we’re TOO productive: too many auto plants making cars no-one can afford to buy. So the surplus went to financial ponzi schemes instead of shortening the workweek and re-employing people in the sectors named above.”
    Exactly. I’m writing a post now that describes how a society gets into the trouble that we are now in. The society postpones investments in education and health, while spending on military and consumption–
    When we could have been
    investing in our public schools, healthcare, the environment and safe, low-income housing we instead have been producing gas-guzzingling SUVs, junk food and those derivatives based on sub-prime mortages.
    None of this added to the wealth of the nation.
    But wealth was growing among the richest 10% of all Americans, and as their wealth grew they used that money to speculate, building bubbles in the stock market, in real estate and in those mortgage-backed derivatives.
    It was a case of too much money chasing too few goods.
    Now, as you say, we need to invest in things of real and lasting value.
    Long-term home health care would both improve the health of the nation, and save some of the $50 billion a year that we are now spending on genrally poor nursing home care.
    And home healthcare givers will spend the money they earn, stimulating the economy.
    Barry–
    Did you realize that Germany, France, the Netherlands, Austria, Italy, Sweden and Japan–just to name a few–all provide long-term care
    for their citizens?
    Germany has one of the most successful systems. Patients have a choice of cash to use for home health care, a nursing home, or a professional home aide. If they take the cash they can pay relatives. (In Austria, Italy and the Netherlands they also can employ relatives.)
    The patients are evaluated, in their homes, to see if they need care.
    You predict that relatives would scam the system. Apparently not, at least in Germany. (You don’t want to suggest that American are simply less honest, do you?))
    The German program has been gong since 1995; everyone in the country is eligible, and the most recent reports show that their is plenty of money in the system to keep it going, even as the population ages.
    It is financed by a 1/2 percent tax on income.
    I can imagine that you will have many questions about these European systems–how they are financed, who is eglible and so forth. I suggest you do what I did: Google “long-term care” and “paying relatives” and Europe. You’ll find many sources.
    The U.S., by the way, spent $100 billion on insitutional long-term care last year and $50 billion on home health care.
    Medicare and Medicaid paid 60% of the tab. The care elderly patients receive in the U.S. is considered very low quality.
    We have written about the nursing homes. Home health aides are paid so poorly that turnover can be high.
    Meanwhile 20% of incapacitates elderly Americans report receiving no care.
    Europeans, by contrast, are willing to care for their elderly.
    Here, if you want government to help you with long term care, you first have to spend virtually all of your own money–down to $4,000. Then you will be eligible for Medicaid.
    We are the only country in the world that insists that people bankrupt themselves if they want health care. I’m curious–just who do you think should provide home health care for elderly people who find themslves bedridden for 20 years?
    Imagine that your wife breaks her hip at age 70–and nver recovers from teh injurty.At about that that time she goes blind from acute macular degerenation (no cure; it will be the leading cause of blindness among baby-boomers in the U.S.)
    Let’s say you have spent you life as a high-school teacher, and put three children through college. Because you are frugal, you have managed to save for the college tuitions and, at 65, have $250,000 in retirement savings –to last you and your wife the 30 additonal years that you may now live.
    You couldn’t afford to buy long-term care insurance–and even if you had tried, your wife wouldn’t have qualified because she had breast cancer at a relatively early age.
    A really good full-time caregiver for your wife would cost $4500 per month (what David paid.) That’s $54,000 a year. You know you can’t afford to run through your $250,000 nest egg that quickly.
    So you become your wife’s full-time care-giver.
    She lives for another 25 years–to age 95. During that time, she experiences some senile dementia and suffers from congestive heart failure.
    After you have been caring for her for 22 years, you overhear two neighbors talking. One asks: “Do you think Barry will ever give up caring for his wife?” The other replies: “People who care for loved ones are not likely to quit despite the emotional and financial costs because they are doing it out of a combination of love and duty. . . . Besdies, he has no choice. Even he did quit, this country doen’t have the physical and human resources to care for his wife. They’d have to warehouse her in a state mental hospital.”
    White Coat– It costs much more to care for people in nursing homes that in their own homes. If you think about it the infrasture–the home, the bed, the bathroom –it’s already there. You just have to pay for a home healthcare nurse, and perhaps a wheel chair, a hospital bed . ..
    The one-on-one care is of course better than the care one will receive in the nursing home, but the cost is still much lower (which is why Medicaid has been trying to encourage more in-home care.)
    Dr. Rick –
    Yes! I agree.
    Lynn — Yes, I agree home healthcare aides should be better paid. It is a demanding job, and an important job.
    In Germany, they are paid 205 to 666 Euros per month–depending on how much care the patient needs and are given a 4 week paid vacation each year (the government sends in a subsitute for four weeks)
    The government also provides them with a generous pension.

  7. raises a few real basic questions:
    1. is this a medical issue at all? fact that folks need help in daily life isn’t necessarily, which is why conventional health insurance, including medicare typically do NOT pay either for institutional care or aides for daily living.
    2. raises provocative questions for the level playing field bunch. if you pay folks to care for their failing parents, why not pay stay-at-home moms who care for their kids.
    3. finally, all agree that there’s tremendous waste in the system and many agree this would be a good idea. but when it comes to squeezing our the waste in today’s system, there’s no agreement at all, which means you can’t get to that money.

  8. Jim–
    Thanks for commenting.
    This isn’t about the elderly who need help in daily life (getting groceries, cleaning the house)
    This is about people who can’t go the bathroom on their own, need someone to give them their medication,
    need to be turned so that they don’t develp gruesom bedsores, etc.
    This really is healthcare.
    Why not pay stay-at-home moms to care for their kids? A couple of reasons.
    First, if children go into daycare it costs taxpayers much, much less than if the elderly go into nursing homes.
    Secondly, caring for your kids is much more fun than caring for an elderly person in diapers. If I had had 5 children, maybe 2 1/2 or 3 years apart, I could imagine making a very satisfying career out of raising them–teaching them, watching them develop, etc.
    Caring for people at the other end of life requires very special people — it’s not fun to watch somone wind down, lose their faculties, etc. There are people who are gifted in caring for the elderly, but they are in the minority.
    By contrast, the majority of parents enjoy spending time with their young children. I’m not suggesting that caring for young children is easy: it requires great patience, creativity, etc.
    Finally, I totally agree: we do need to unlock that wasted money. That will take spine on the part of Congress–standing up to the lobbyists.
    We’ll see if that happens

  9. Reply by David Cundiff, author of the post:
    Thanks to Barry Carol and Jim Jaffe for their posts.
    I was worried that everyone would agree immediately and then nothing would happen. The German philosopher Arthur Schopenhauer said, “All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.” The first person I floated the idea of paying home care workers on asked if I proposed it “tongue in cheek.“ Now that we have passed the ridicule stage, let’s get to the violent opposition.
    Barry’s first point: “I think any economist will tell you that $360 billion PER YEAR plus inflation adjustments in the future is cost prohibitive when we already have a huge federal budget deficit even without counting the cost of the stimulus package and the financial system rescue effort.”
    Beware of trusting economists. They don’t have a great record of predicting the effects of economic interventions. The country’s most eminent economists talked Congress and President Bush into the bank bailout.
    Currently, it is estimated that bailout of banks gave us $0.06 on the dollar for first $350 billion “invested.” While the new economic stimulus package will create a bubble that might temporarily slow the net loss of jobs, it is extremely unlikely to provide a long-term economic fix.
    Whereas, the President’s optimistic prediction is that his proposed stimulus will create 3-4 million jobs, paying home care workers is guaranteed to create up to 46 million jobs for mostly poor people who will immediately spend the money for necessities.
    The stimulus package of the President and Congressional Democrats offers no plan to recover the money other than hoping that somehow the economy improves.
    I’m proposing that the $360 billion per year come from comprehensive health care reform. The President rightly said that health care reform cannot be deferred until we fix the economy, because it is a major cause of our financial crisis.
    If health care reform results in saving $1 trillion per year at the cost of 2 million high paying but unnecessary health care jobs and pay cuts for many others, it will fail.
    To succeed in today’s economic climate, health care reform must result in a net increase in jobs and cost the same or less money than we now spend. Paying home care workers is one way to have a huge net increase health care related jobs while millions of health care bureaucrats and some practitioners lose their jobs or transition to other health care employment due to health care reform.
    Next Barry says, “People who care for loved ones are not likely to quit despite the emotional and financial costs because they are doing it out of a combination of love and duty. Even if they did quit, we don’t have the physical and human resources to care for their loved ones in nursing homes, assisted living facilities or in their own homes with help from home healthcare workers.”
    In my days of practicing medicine at the LA County + USC Medical Center (a charity hospital), we did have plenty of “social hospitalizations” in which the exhausted family gave up and dropped off their disabled elderly relative at our emergency room. However, I agree that the friends and family of the elderly and disabled are not all likely to quit and admit their loved ones to long term care institutions. I’m arguing that it is both socially just for the government to pay family and friends for doing home care and economically expedient for the country. The economic multiplier effect of small salaries to tens of millions of previously unpaid workers could help lift up out of the recession.
    Barry’s next point: “It would also likely be administratively impossible to reward family members with either tax credits or actual pay to care for their loved ones.
    How would we verify the hours they worked? Even people who live with or near loved ones who don’t need any help could game the system by claiming that they spent 10 or 20 hours a week or whatever providing care.”
    Virtually all health care policy experts agree that a crucial aspect of health care reform is revitalizing primary care and affording all people a medical home which coordinates all treatments, including long-term care. Rather than Washington, DC bureaucrats administering the home care benefit to individuals, I propose that each disabled person’s primary care physician determine the number hours of assistance required for that person and order accordingly.
    The PCPs would order visiting nurse agencies or other appropriate monitors to provide periodic reports to the physician about the home care. Medicaid’s pilot project, “Cash and Counseling,” has shown that allowing the disabled person flexibility with home care funds, including paying family and friends for services, works very well.
    Barry’s last point, “If long term care were ever covered fully by Medicare, people would come forward literally by the millions to claim benefits. Universal long term care coverage is unaffordable by any measure, and that’s why it will probably never happen.”
    True, government coverage of long-term care will be costly. However, when you consider the effects on uncompensated caregivers, the needless suffering of disabled people with inadequate care, and cost of unnecessarily institutionalizing disabled people; the overall cost to society of the government not covering long-term care will greater, especially as the baby boom reaches old age.
    Maggie did a great job in reviewing the government-funded long-term insurance programs in other developed countries (below).
    We are paying about twice as much per capita for health care as these countries and do not have universal long-term care insurance. Successful health care reform in this country requires the inclusion of universal long-term care insurance.
    Jim Jaffe says, “….conventional health insurance, including medicare typically do NOT pay either for institutional care or aides for daily living.”
    True, government insurance coverage of long-term care, including paying for family and friends to provide services, would be a big new entitlement.
    Jim’s second point, “….. if you pay folks to care for their failing parents, why not pay stay-at-home moms who care for their kids.”
    Maggie’s points are well taken in that regard.
    Point #3: “all agree that there’s tremendous waste in the system and many agree this would be a good idea. but when it comes to squeezing out the waste in today’s system, there’s no agreement at all, which means you can’t get to that money.”
    America has had great challenges before and met them with determination and innovation. If we can’t achieve comprehensive health care reform, we can’t have economic recovery. Health care reform is possible and urgently needed both for our economic recovery and for improving the health of our people.

  10. I appreciate the detailed response (through Maggie) from Dr. Cundiff. If we could actually reform the healthcare system in a way that realizes savings in the hundreds of billions, it would, at least in theory, be more affordable to provide universal long term care. His explanation of the role of PCP’s in determining the amount of care needed was also helpful. We do, however, already have a shortage of primary care doctors and I’m not sure how easy it would be to find, attract and train tens of millions of home healthcare workers who would be willing to take the often demanding jobs for the modest salaries that the society could afford to pay.
    There is obviously a lot of waste in the system now, but it is often not easy to identify it ahead of time at the individual patient level. With heart patients, for example, how do we identify which specific patients who received a stent didn’t really need one and would have been just as well off with much cheaper medical therapy instead? To drive utilization down, I think we are going to have to develop the political will to just refuse to cover and pay for expensive cancer drugs and other treatments and procedures that are deemed by an independent Federal Health Board not cost effective.
    While Maggie has been vocal in her criticism of drug companies and insurers and wants to tighten regulation and reduce the profits of those sectors to save money, I think the biggest obstacles to reform will be doctors and hospitals. Just recently, for example, the AMA helped to defeat a suit brought by Consumer Checkbook seeking the release of Medicare claim data by physician so it could be used to identify which doctors are high utilizers and which aren’t. The AMA has also fought against medical clinics in drug stores and big box retailers like Wal-Mart.
    As for hospitals, when they are not killing us with hospital acquired infections, they are killing us financially. I would like to cite a few examples of astronomical charges from hospitals in NYC and its suburbs for care that was appropriate, well delivered and resulted in positive outcomes. A few months ago, a friend needed hip replacement surgery following a slip and fall accident. The total episode cost about $130K at list price with insurance paying about half. The hospital billed $78K for a six day stay and its rehabilitation unit billed another $26K for 8 days. The surgeon billed just shy of $18K for an operation that took about two hours or a bit more. Another friend had a hip replacement about a year ago after putting it off for years – as long as he possibly could. His surgeon billed $17K and was paid about $11K. In late 2005, I was sent for angiography after an adverse change on my stress test. A blockage was found and one stent was inserted. The whole procedure took about a half hour. I was kept overnight and sent home the next day around lunchtime. The hospital billed $31K while insurance paid $19K. The doctor billed another $5K. I wonder how these prices compare to what is typically paid (and accepted as full payment) in Europe and Canada. These charges strike me as the equivalent of paying $1,000 for a steak. Even if it’s the best meat in the world, at some point, it just offends one’s sense of value for money. And these are all NON-PROFIT institutions. Specialists are almost as bad. When I see my urologist for my annual checkup, I usually get a couple of ultrasounds, a flow rate test, and a little consulting at the end. The whole process takes 20-30 minutes. For this, he usually bills close to $2,000 of which insurance pays about $650. Even the most senior partners of Wall Street law firms “only” bill at $1,000 per hour or so. The PCP’s are certainly not the problem in generating high bills. It’s the hospitals and the specialists, and that’s where I think the focus needs to be.

  11. I think you all need to look at the future demographic projections in both the US and Europe and the number of workers outside the health care field that will be available to support the elderly. Then Google the health care budget deficits in Europe and see which areas they cut into first to balance their budgets, Long term care, ie Netherlands etc. (In the long run Europe is worse off than we are just from a demagraphic stand point). Then read the EU commission paper on health inequalities and how they acually got wider not narrower over the last 20 years in Europe. Their words not mine. Everyone wants to see things get better, this just ain’t it.

  12. Regarding Barry Carrol’s comments
    #1. “ I appreciate the detailed response (through Maggie) from Dr. Cundiff. If we could actually reform the healthcare system in a way that realizes savings in the hundreds of billions, it would, at least in theory, be more affordable to provide universal long term care.”
    Let me summarize. Any change in the health care system that does not realize saving of over $1 trillion out of the $2.7 trillion we are projected to pay in 2010 is not health care reform. A successful resolution of the current financial crisis is impossible without health care reform, because health care costs and inflation in medicine are a major cause of our crisis. Because of the crisis in unemployment, health care reform must increase not decrease jobs while saving money. Paying home health care workers would provide the needed net increase in health care jobs to boost the economy, allowing reform to rid us of unnecessary jobs.
    #2 “We do, however, already have a shortage of primary care doctors….”
    Another essential ingredient of health care reform is improving the pay and working conditions of primary care practitioners (MDs, osteopaths, physicians’ assistants, and nurse practitioners). In all developed countries with better health care outcomes and lower costs than the USA, all residents have a primary care provider who coordinates the care.
    #3 “…..and I’m not sure how easy it would be to find, attract and train tens of millions of home healthcare workers who would be willing to take the often demanding jobs for the modest salaries that the society could afford to pay.”
    It is not necessary to find, attract and train the 46 million home health care workers that I am talking about. They already provide care each day to their loved ones, often at great personal sacrifice to themselves. An estimated 138 million Americans (68% of the adult population) think that in the future they will be providing home care to a loved one and about 50% of the population will require long-term care services, so you will probably be either doing this job or the recipient of these services from your family and friends in the future.
    #4 “There is obviously a lot of waste in the system now, but it is often not easy to identify it ahead of time at the individual patient level. With heart patients, for example, how do we identify which specific patients who received a stent didn’t really need one and would have been just as well off with much cheaper medical therapy instead?”
    In my view, another essential component of health care reform is getting away from determining insurance coverage by ‘one size fits all’ medicine manifested by top-down treatment guidelines drafted by government and academic health care experts. This point is highly controversial. Health care policy wonks favoring government-run single-payer model like Canada or Great Britain want more conformity to official treatment guidelines in order to control costs. For instance, the American Recovery and Reinvestment Act of 2009, passed by the House of Representatives, includes $1.1 billion for comparative effectiveness research to, among other things, form a scientific basis for denying insurance coverage for non-beneficial expensive treatments.
    The example that you raise illustrates the point very well. Percutaneous coronary interventions (PCIs = angioplasties with or without stents) as treatment for people with coronary artery blockages has been considered standard care and paid for by public and private insurance for at least 25 years. About 65% are performed in people with stable coronary blockages and 35% in those with acute problems (acute coronary syndromes including heart attacks). In 2007, a randomized comparison of PCI versus medical treatment alone in people with stable coronary blockages showed no benefit of PCI in survival or control or chest pain. Together with the results of 11 previous studies, these data have begun to swing some cardiology opinion and much public opinion away from PCI for stable coronary disease. Acknowledging that PCI for stable coronary disease is and always has been ineffective treatment means realizing that at least 10 million PCIs for stable coronary disease over the past 30 years have cost the country over $4 trillion in today’s dollars and about 80 thousand lives from immediate complications. In my view but not in the opinion of cardiology experts, PCIs for acute coronary syndromes and heart attacks are likewise ineffective. A review of all seven randomized trials comparing PCI with medical treatment alone showed that PCIs cause higher in-hospital mortality (1.8 versus 1.1%) and no proven significant long term reduction in mortality.
    While the efficacy of PCI for anyone is highly controversial, the American Heart Association/American College of Cardiology Guidelines still endorse them and government and private insurance companies keep paying about $40,000 – $60,000 for each one. With the current top-down one size fits all expert guideline system of determining insurance coverage, we have to wait for the consensus of cardiology experts to change and realize that PCIs don’t work. I don’t have to tell you that there is a conflict of interest in allowing cardiologists to make this determination. A system that is not one size fits all would allow insurance companies or better yet doctors to choose whether or not to pay for PCIs and allow consumers to choose insurance companies or doctors according to their preferences.
    #5 “To drive utilization down, I think we are going to have to develop the political will to just refuse to cover and pay for expensive cancer drugs and other treatments and procedures that are deemed by an independent Federal Health Board not cost effective.”
    You have too much faith in an “independent” Federal Health Board. In top-down systems of producing guidelines, money trumps objectivity as has been amply shown by the FDA’s system of determining what drugs to approve for what medical indications. Forgetting for the moment cheap and safe medical tests and treatments, we need to acknowledge that the benefit to patients of many if not most expensive and risky medical tests and treatments is controversial, like PCI above. A free market in health care could better get rid of the waste compared to one size fits all top-down government knows best approaches. In every realm of controversy about effectiveness of medical interventions, give people choices. Using the above example, allow people with heart disease to choose a health plan that pays for PCI and conventional American Heart Association cardiac rehabilitation or another plan that does not cover PCI but does cover an aggressive more expensive cardiac rehabilitation program.
    #6 “While Maggie has been vocal in her criticism of drug companies and insurers and wants to tighten regulation and reduce the profits of those sectors to save money, I think the biggest obstacles to reform will be doctors and hospitals. Just recently, for example, the AMA helped to defeat a suit brought by Consumer Checkbook seeking the release of Medicare claim data by physician so it could be used to identify which doctors are high utilizers and which aren’t. The AMA has also fought against medical clinics in drug stores and big box retailers like Wal-Mart.”
    Gouging by drug companies, insurers, doctors, and hospitals are all dependent on standard guidelines determining what medical interventions are covered by insurance and what ones are not. A RAND study of the quality of care in America found that we are only getting about 55% of all the tests and treatments required by orthodox medical establishment guidelines. Consequently, if you accept that we need all the medical interventions called for by government and academic experts, then we will need about $4.7 trillion instead of $2.7 trillion in 2010 to optimize health care. The alternative view to this absurdity is that many officially endorsed guidelines have been corrupted by financial conflicts of interests in one way or another. Only a free market in health care services can overcome the financial conflicts throughout our dysfunctional system.
    #7 “As for hospitals, when they are not killing us with hospital acquired infections, they are killing us financially. I would like to cite a few examples of astronomical charges from hospitals in NYC and its suburbs for care that was appropriate, well delivered and resulted in positive outcomes. A few months ago, a friend needed hip replacement surgery following a slip and fall accident. The total episode cost about $130K at list price with insurance paying about half. The hospital billed $78K for a six day stay and its rehabilitation unit billed another $26K for 8 days. The surgeon billed just shy of $18K for an operation that took about two hours or a bit more. Another friend had a hip replacement about a year ago after putting it off for years – as long as he possibly could. His surgeon billed $17K and was paid about $11K. In late 2005, I was sent for angiography after an adverse change on my stress test. A blockage was found and one stent was inserted. The whole procedure took about a half hour. I was kept overnight and sent home the next day around lunchtime. The hospital billed $31K while insurance paid $19K. The doctor billed another $5K. I wonder how these prices compare to what is typically paid (and accepted as full payment) in Europe and Canada. These charges strike me as the equivalent of paying $1,000 for a steak. Even if it’s the best meat in the world, at some point, it just offends one’s sense of value for money. And these are all NON-PROFIT institutions. Specialists are almost as bad. When I see my urologist for my annual checkup, I usually get a couple of ultrasounds, a flow rate test, and a little consulting at the end. The whole process takes 20-30 minutes. For this, he usually bills close to $2,000 of which insurance pays about $650. Even the most senior partners of Wall Street law firms “only” bill at $1,000 per hour or so. The PCP’s are certainly not the problem in generating high bills. It’s the hospitals and the specialists, and that’s where I think the focus needs to be.”
    My condolences to you and others who endure outrageous charges for hospital and specialist care. I agree that primary care providers are not the problem. Indeed, PCPs, in my view, are the solution. With my health care reform proposal, “Doctor Managed Care,” each PCP or group of primary care providers would determine which tests and treatments to cover with insurance and which would not be covered. Consumers could then choose their PCPs based in large part on how they want their health care dollar spent. For instance, a PCP of a patient needing a hip replacement could have the best local orthopedists bid on doing the operation. If all the bids came in at over $30,000, the PCP might send the patient to India to have it done for $10,000 -$15,000, including airfare, hotels, and private duty nurses. As a PCP in Doctor Managed Care, I would not cover PCIs, but I would offer patients state of the art programs with diet, exercise and stress management. Likewise, I wouldn’t cover routine yearly urological testing for people with prostate problems, but I would seek urologic consultation if I thought surgery might be indicated.
    Thanks, Barry. I couldn’t have planted better questions if I had tried.
    Posted by: Barry Carol | February 08, 2009 at 04:44 PM
    Regarding James D.’s points,
    #1 “I think you all need to look at the future demographic projections in both the US and Europe and the number of workers outside the health care field that will be available to support the elderly.”
    According to the trustees, Medicare’s long-term debt, based on a 75-year actuarial projection, is now estimated to be $32.4 trillion, unsustainable to say the least.
    #2 “Then Google the health care budget deficits in Europe and see which areas they cut into first to balance their budgets, Long term care, ie Netherlands etc. (In the long run Europe is worse off than we are just from a demagraphic stand point). Then read the EU commission paper on health inequalities and how they acually got wider not narrower over the last 20 years in Europe. Their words not mine. Everyone wants to see things get better, this just ain’t it.”
    Over the long term, the health care systems of European countries are as unsustainable as our system. That’s why modeling our health care reform plan on Canada or a European country will not work. We need a plan that recreates a functional health care market. It may be paid for by the government but not run by the government. Consider Doctor Managed Care.

  13. Dr. Cundiff,
    Thanks very much for this very interesting and informative exchange. Your comments trigger a few other questions from a patient’s perspective.
    First, if I’m shopping for insurance under your approach, how many permutations and combinations of coverage might there be to choose from? It sounds like there could be a very large number. Would the doctor managed care groups also underwrite the insurance as part of an independent practice association or would insurers pay them on a capitation basis to provide or contract for all care covered by the policy? What happens if I need care when I’m far from home? How would you deal with end of life care including late stage cancer and dementia cases? Would there be a checklist of diseases and conditions that each doctor managed care group would indicate which ones it covered and which ones it didn’t cover?
    Conceptually, I like your proposal to give people choices as opposed to forcing them to accept a one size fits all government knows best approach. However, I can already here progressives claim that huge segments of the population (the poor, elderly, uneducated, etc.) won’t be able to choose wisely and in their own best interests. Perhaps they’ll be misled or duped by insurance brokers trying to peddle policies that pay the highest commissions. Or, they will claim they didn’t understand what they signed up for. Or, while they agreed to forgo care for, say, late stage cancer, once they were faced with it, they decide they want the care and are looking for someone to sue to force providers to give it to them. One size fits all avoids a lot of those complexities.
    I remember some years back the state of Oregon tried to prioritize some 600 or so different diseases and conditions in order to efficiently allocate limited Medicaid resources. If we could determine a QALY based cost-effectiveness score for all of those conditions, I could envision an insurer offering to cover everything costing $75K per QALY or less at one price, $100K or less at a higher price, $150K or less for a still higher price, etc. Experts could determine the QALY scores and post them on a website for all to see and keep the data up to date to reflect evolving technological advances and new treatment innovations.

  14. Regarding Barry Carroll’s questions about my comprehensive health care reform proposal, “Doctor Managed Care,” I am currently revising the plan based on new information and critiques of all those interested. Let me know what sounds crazy or what could be done in a better way. The detailed answers to Barry’s questions about Doctor Managed Care are in my free online book, Money Driven Medicine—Tests and Treatments That Don’t Work, (http://www.doctormanagedcare.com Chapter 24). Here are the short answers.
    #1. “First, if I’m shopping for insurance under your approach, how many permutations and combinations of coverage might there be to choose from? It sounds like there could be a very large number.”
    Right. Each primary care physician or group of PCPs would determine the tests and treatments covered by insurance for their patients. As is now the case, physicians’ assistants and nurse practitioners could provide primary care services under the supervision of an MD or osteopathic physician. PCPs would average caring for about 1000 patients instead of 2500 – 3000 currently. Considering that many like-minded PCPs would practice in groups and that physician assistants and nurse practitioners would practice under PCP supervision, there could be about 100,000 – 150,000 permutations and combinations of coverage (300 million population / 1000 patients per primary care provider = 300,000 primary care providers. If, on average, 2-3 providers form groups the possible plans would be 100,000 -150,000).
    #2. “Would the doctor managed care groups also underwrite the insurance as part of an independent practice association or would insurers pay them on a capitation basis to provide or contract for all care covered by the policy?”
    For each patient, the federal government as the single-payer would pay a risk-adjusted allocation to the PCP’s insurer. Insurance companies would also collect and administer co-premiums from patients ($100 per month per adult and $5 per month per child). On a case by case basis, PCPs could wave or adjust the co-payments or offer service opportunities in lieu of premiums. In 2010, the average PCP with 1000 patients would receive about $7.5 million per year ($7500 per patient x 1000 patients) for the health services to his/her patients. The insurer would pay for all health interventions authorized by the patient’s PCP. It would be to the advantage of each PCP and his/her patients to have the most efficient allocation of those funds. How to do that for each practice will be different and constantly changing.
    #3. “What happens if I need care when I’m far from home?”
    Your PCP could authorize payment for any care that he/she felt justified.
    #4. “How would you deal with end of life care including late stage cancer and dementia cases?”
    It would be up to each PCP. From my long experience as a palliative care/hospice physician consultant, I will bet that PCPs who provide state-of-the-art palliative care will be more popular with patients and families than PCPs who continue grueling and expensive acute care treatments in hospitals in these kinds of cases.
    #5. “Would there be a checklist of diseases and conditions that each doctor managed care group would indicate which ones it covered and which ones it didn’t cover?”
    PCPs would cover all diseases and conditions. They would vary as to what tests and treatments they would provide for those diseases and conditions.
    #6. “Conceptually, I like your proposal to give people choices as opposed to forcing them to accept a one size fits all government knows best approach. However, I can already here progressives claim that huge segments of the population (the poor, elderly, uneducated, etc.) won’t be able to choose wisely and in their own best interests. Perhaps they’ll be misled or duped by insurance brokers trying to peddle policies that pay the highest commissions. Or, they will claim they didn’t understand what they signed up for. Or, while they agreed to forgo care for, say, late stage cancer, once they were faced with it, they decide they want the care and are looking for someone to sue to force providers to give it to them. One size fits all avoids a lot of those complexities.”
    Insurance companies would have no direct contact with patients. They would compete among themselves to be selected by PCPs to receive the risk-adjusted government funds and co-premiums from patients and to administer the payments for health services for patients. Among the poor, wealthy, and everyone else there will arise disputes about what tests and/or treatments or particular specialists are covered. When a patient wants a test or treatment or consultant specialist that the PCP doesn’t cover, the options would be: (1) except the PCP’s alternative approach to the problem, (2) pay for the desired intervention out of pocket, (3) change to a PCP that did cover the test or treatment or specialist consultant, or (4) petition a practice review committee consisting of other patients of the PCP about a variance to the denial of coverage. This would apply to late stages of cancer or anything else.
    #7. “I remember some years back the state of Oregon tried to prioritize some 600 or so different diseases and conditions in order to efficiently allocate limited Medicaid resources. If we could determine a QALY based cost-effectiveness score for all of those conditions, I could envision an insurer offering to cover everything costing $75K per QALY or less at one price, $100K or less at a higher price, $150K or less for a still higher price, etc. Experts could determine the QALY scores and post them on a website for all to see and keep the data up to date to reflect evolving technological advances and new treatment innovations.”
    I have found that studies of cost-effectiveness using quality adjusted life years (QALY) methodology are generally funded by special interests that provide the tests or treatments being analyzed. Many times, I find a QALY assessment to be worthless, because, in my judgment, the test or treatment itself doesn’t provide any benefit or a less expensive alternative exists. Controversy is inevitable in health care. That’s why I oppose insurance company or government treatment mandates (guidelines), drafted by academic and/or government experts, many with financial conflicts, as the determiner of insurance coverage in individual patients. Doctor Managed Care would move that crucial coverage determining function from anonymous experts to your own PCP.
    Again, I am open to improvements to the Doctor Managed Care idea. Thanks again for your questions.

  15. Let me add just one comment to this discussion:
    guidelines based on “comparative effectiveness” information do not lead to One Size Fits All medicine.
    These guidelines always distinguish between patients who fit different profiles–varying by age, co-morbidites, whether a sibling had the disease (making the patient high-risk) tolerance for certain side effects, etc.
    Leaving it up to the provider is much more likely to lead to “one size fits all” medicine. Reserach shows that providers who favor a praticular drug or procedure tend ot give it to all of their patients–whether it’s a mastectomy or Lipitor.
    Like everyone, doctors develop habits. And today, no physician can keep up with all of the research–even in his own specialty.
    That’s why we need a an unbiased board at the top reviewing and putting together comparative effectiveness reserach.
    When I interviewed him as the heatlhcare conference last week, Princeton economist Uwe Reinhardt suggested it should be somone like the Robert Wood Johnson foundation–not a bad idea. They are free from conflicts of interest and genrally focused on what is best for patients. Period.

  16. Dr. Cundiff,
    Your ideas are certainly provocative to say the least, and I’ll look forward to reading your book. I still have quite a few questions, though.
    For example, I’m not sure I understand how PCP’s would be paid under your system and how they are rewarded for efficient utilization of healthcare services. How are incompetent doctors weeded out and disciplined? How do I find out about a given doctor’s or group of doctors’ qualifications, years of practice experience, certification, if any, how many times they have been successfully sued for malpractice (vs. peers) and how many doctors and nurses they have as patients? How easy would it be to change doctors if I’m not satisfied or if we just don’t get along well in a personal chemistry sense? What resources are available to me to learn about the quality and capabilities of the specialists and hospitals to which I may be referred?
    What happens if I am refused a referral for an MRI, I decide to pay for it myself, and it turns out that I have brain cancer? Would the necessary treatment then be covered and how much confidence am I likely to have in that PCP or group of PCP’s in the future? Answer: none. Hundreds of thousands of doctors, both PCP’s and specialists vary widely in capability, while the resources available to the average person to distinguish between the good and not so good are woefully inadequate at best. Personally, I wouldn’t assign much credence at all to patient satisfaction surveys because so many patients evaluate doctors on the three A’s – affability, availability, and last and least, ability. Give me good cognitive and diagnostic skills along with good communications skills and reasonable availability. While affability is nice, I’m even willing to tolerate a certain amount of arrogance if he or she can treat my medical issues skillfully and efficiently.
    I’m also not comfortable cutting insurers out of the medical decision making loop. Doctors and hospitals have been known to commit fraud including billing for treatments never performed and putting patients through unnecessary treatments to drive revenue. Insurers have sophisticated data analytics capability to catch a lot of this. Additionally, notwithstanding the possible conflicts that you mentioned in earlier comments, I would be more than willing to at least give a Federal Health Board a chance to make judgments about treatments that we should probably not pay for because they are not cost-effective. If the patient still wants such treatments, he or she can self-pay.
    I was hoping that more people, especially some of the doctors who comment on this blog, would jump in here because it is a fascinating discussion and your perspective is completely new to me.

  17. Thanks to Maggie and Barry for additional comments. I’ll begin with Maggie’s.
    #1. …..”guidelines based on “comparative effectiveness” information do not lead to One Size Fits All medicine.
    These guidelines always distinguish between patients who fit different profiles–varying by age, co-morbidities, whether a sibling had the disease (making the patient high-risk) tolerance for certain side effects, etc.”
    This is a big topic and I have a few things to say. Let me begin with a definition.
    In a report requested by Congress, “Research on the Comparative Effectiveness of Medical Treatments: Issues and Options for an Expanded Federal Role (http://www.cbo.gov/ftpdocs/88xx/doc8891/12-18-ComparativeEffectiveness.pdf),” Peter Orszag, then Director of the Congressional Budget Office and now the Obama Administration’s Budget Director, defines comparative effectiveness:
    “As applied in the health care sector, an analysis of comparative effectiveness is simply a rigorous evaluation of the impact of different options that are available for treating a given medical condition for a particular set of patients. Such a study may compare similar treatments, such as competing drugs, or it may analyze very different approaches, such as surgery and drug therapy. The analysis may focus only on the relative medical benefits and risks of each option, or it may also weigh both the costs and the benefits of those options. In some cases, a given treatment may prove to be more effective clinically or more cost-effective for a broad range of patients, but frequently a key issue is determining which specific types of patients would benefit most from it. Related terms include cost–benefit analysis, technology assessment, and evidence-based medicine, although the latter concepts do not ordinarily take costs into account.”
    Maggie is right that guidelines based on comparative effectiveness research do not lead to one size fits all medicine. However, this is because comparative effectiveness research rarely leads to clinical practice changes that save money. Scientific evidence that expensive tests and treatments covered by insurance are ineffective or less cost effective than competing medical interventions appears all the time. However, it rarely if ever results in adopting the less expensive intervention. Money trumps scientific research findings. Let me illustrate with two of Mr. Orszag examples showing inexpensive interventions to be better than established insurance reimbursed expensive interventions:
    (1) Pg 12 (http://www.cbo.gov/ftpdocs/88xx/doc8891/12-18-ComparativeEffectiveness.pdf )“A recent example of a comparative effectiveness study indicates that careful analysis can sometimes disprove widely held assumptions about the relative merits of different treatments. The study, which involved patients who had stable coronary artery disease, compared the effects of two treatments: an angioplasty with a metal stent combined with a drug regimen versus the drug regimen alone. Patients were randomly assigned to receive the two treatments, and although the study found that patients treated with angioplasty and a stent had better blood flow and fewer symptoms of heart problems initially, the differences declined over time. More importantly, it found no differences between the two groups in survival rates or the occurrence of heart attacks over a five-year period.”
    Mr. Orszag referenced the “COURAGE (http://content.nejm.org/cgi/content/full/NEJMoa070829v1) ” trial published in March 2007, implying that the negative results of this large randomized trial should favor abandoning angioplasties in people with stable coronary artery disease. I mentioned this in response to Barry’s question previously. The COURAGE trial was published in the New England Journal of Medicine and funded mostly by drug companies that have a stake in increasing the market share of pharmaceuticals in the coronary heart disease market (Merck, Pfizer, Bristol-Myers Squibb, Fujisawa, Kos Pharmaceuticals, Datascope, AstraZeneca, Key Pharmaceutical, Sanofi-Aventis, First Horizon, and GE Healthcare). Many of the COURAGE trial investigators had accepted consulting fees, lecture fees, and research grants from those same companies. The New England Journal of Medicine itself relies heavily on advertising revenue from drug companies and medical device makers like those that market coronary artery stents. If the COURAGE trial results had appeared in an obscure medical journal, the medical media may well have ignored it. After the COURAGE trial was published, the American College of Cardiology together with the American Heart Association updated their joint guidelines for the use of angioplasty (http://guidelines.gov/summary/summary.aspx?doc_id=12193&nbr=006290&string=heart+AND+disease). In this update, angioplasty was still recommended for patients with stable coronary artery disease. The six researchers drafting the updated guidelines included two with financial relationships with angioplasty and stent devise makers and two with financial relationships with drug companies in the coronary artery disease market. One had financial relationships with both constituencies. Did the comparative effectiveness research showing that angioplasty did not save lives have a negative effect on sales of stents or numbers of angioplasties in 2008? No (http://seekingalpha.com/article/117469-boston-scientific-corporation-q4-2008-earnings-call-transcript). Sales have continued upwards.
    (2). Pg 13 (http://www.cbo.gov/ftpdocs/88xx/doc8891/12-18-ComparativeEffectiveness.pdf) “One recent trial found that older, relatively inexpensive drugs for treating high blood pressure (known as diuretics) were more effective in preventing cardiovascular disease in patients age 55 or older than commonly used newer drugs known as angiotensin converting enzyme inhibitors and calcium channel blockers.”
    This widely-reported trial, ALLHAT (http://jama.ama-assn.org/issues/v288n23/rfull/joc21962.html), did not result in any substantial change in practice patterns of physicians to use inexpensive diuretics in preference to angiotensin converting enzyme inhibitors or calcium channel blockers. Additionally, the ALLHAT comparative effectiveness randomized trial did not include a placebo control group for people with mild hypertension (stage 1, i.e., diastolic blood pressure 90-99 and/or systolic blood pressure 140-159). In my view, the evidence does not support any drug treatment for stage 1 hypertension. I have a protocol to review the evidence-based literature on this subject with the Cochrane Database of Systematic Reviews (Wright%20JM,%20Cundiff%20DK,%20Gueyffier%20F.%20Antihypertensive%20drugs%20for%20mild%20hypertension.%20(Protocol).%20Cochrane%20Database%20of%20Systematic%20Reviews.%202007(Issue%203):Art.%20No.:%20CD006742.%20DOI:%20006710.001002/14651858.CD14006742). Since about 60% of people with hypertension have stage 1 disease, it would cost drug companies up to $10 billion if research concluded that drugs do not benefit clinical outcomes in patients with stage 1 disease. This explains why it is extremely difficult to get challenges to the effectiveness of drugs for stage 1 hypertension into the peer-reviewed medical literature.
    I review the topic of biases in evidence-based medicine research in detail in my book (http://doctormanagedcare.com/ChaptersMDM.pdf)—Chapter 1 Evidence Based Medicine and Chapter 2 Evidence Based Medicine Corrupted by Money.
    Maggie’s next point,
    “Leaving it up to the provider is much more likely to lead to “one size fits all” medicine. Research shows that providers who favor a particular drug or procedure tend to give it to all of their patients–whether it’s a mastectomy or Lipitor.
    Like everyone, doctors develop habits. And today, no physician can keep up with all of the research–even in his own specialty.
    That’s why we need an unbiased board at the top reviewing and putting together comparative effectiveness research.”
    In my view, it’s impossible to have an unbiased board in medicine. Witness the FDA or the Center for Medicare and Medicaid Services. The only people who are unbiased about medical interventions are people that don’t know anything about them and are unqualified to evaluate them. If you know of any counterexamples, I would be happy to critique them.
    Maggie’s final point,
    “When I interviewed him as the healthcare conference last week, Princeton economist Uwe Reinhardt suggested it should be someone like the Robert Wood Johnson foundation–not a bad idea. They are free from conflicts of interest and generally focused on what is best for patients. Period. “
    It may well be that the staff of the RWJF are free from conflicts of interest and focused on what is best for patients, but they are also unqualified to use evidence-based medicine methodology to make the very difficult decisions about what should and should not be covered by medical insurance for every patient in the USA. Nobody is that qualified. On the search engine of the RWJF website, I entered “comparative effectiveness” and got 17 hits. Browsing through these results suggested that health care policy experts at RWJF support comparative effectiveness research studies as a means of achieving better cost effectiveness and quality of care. They funded the “Cash and Counseling” program for Medicaid that I mentioned before as showing the effectiveness of paying family and friends to care for their disabled loved ones. With that exception, I didn’t find from this search that they have funded any studies of comparative effectiveness research that have resulted in practices that improve quality while lowering costs. Even the Cash and Counseling program is only a pilot that has not yet resulted in any widespread change in Medicaid’s institutional bias in long-term care. Correct me if I am wrong.
    Of the seven program areas of the RWJF, only “Quality/Equality” might possibly relate to comparative effectiveness research. None of the staff in this program area had a medical degree or PhD in a health care related field. All were administrators. The RWJF would have to hire all new people to serve on a national comparative effectiveness board. While the RWJF currently has a reputation for being unbiased, the issue would be the credentials and selection process for the comparative effectiveness experts that they would hire.
    Great Britain is far ahead of us in applying comparative effectiveness studies including cost effectiveness component to insurance coverage decisions. National Institute for Health and Clinical Guidelines (NICE) leading to denials of drugs for cancer (http://www.timesonline.co.uk/tol/news/uk/health/article4499847.ece.) and macular degeneration (http://www.telegraph.co.uk/news/newstopics/politics/health/2627245/Eyesight-of-thousands-to-be-saved-after-Nice-approves-drug.html) have caused an uproar. The “TaxPayers’ Alliance in London” (http://www.shns.com/shns/g_index2.cfm?action=detail&pk=MURDOCK-02-21-08) accuses the NICE guidelines of killing over 17,000 people and year. Since Americans are far less accepting of government authority in health care than the British, a comparative effectiveness board in this country would be even less popular.
    In drafting a comprehensive health care reform plan, I think you have to assume that the benefit of many medical interventions will always be controversial. That’s one reason why one size fits all medical insurance coverage will never work in this country.
    Regarding Barry’s questions:
    #1. I’m not sure I understand how PCP’s would be paid under your system and how they are rewarded for efficient utilization of healthcare services.”
    All of the details of Doctor Managed Care are open for criticisms. PCPs would receive a capitated reimbursement of about 5% of overall health care services. Since the funds for patient treatment and preventive medicine would be finite, PCPs would have to efficiently utilize health care services to attract and retain patients.
    #2. “How are incompetent doctors weeded out and disciplined?”
    Incompetent PCPs would have difficulty attracting and/or retaining patients. Incompetent specialists would have difficulty getting referrals from PCPs. Disciplining incompetent doctors is a long story that you can read in of my book (Chapter 23: Medico-legal Chaos).
    #3. “How do I find out about a given doctor’s or group of doctors’ qualifications, years of practice experience, certification, if any, how many times they have been successfully sued for malpractice (vs. peers) and how many doctors and nurses they have as patients?”
    All this methods that exist now to find this information would continue to be available. In addition, PCP practice annual reports would available on websites and as hard copies upon request.
    #4. “How easy would it be to change doctors if I’m not satisfied or if we just don’t get along well in a personal chemistry sense?”
    If you could find another PCP that would take you as a patient, you could change.
    #5. “What resources are available to me to learn about the quality and capabilities of the specialists and hospitals to which I may be referred?”
    The same kind of resources as now (i.e., internet searches and word of mouth)
    #6. “What happens if I am refused a referral for an MRI, I decide to pay for it myself, and it turns out that I have brain cancer?”
    That could be negotiated with your PCP.
    #7. “Would the necessary treatment then be covered and how much confidence am I likely to have in that PCP or group of PCP’s in the future?”
    All necessary treatment, as defined by the PCP, would always be covered. You would be free to change PCPs. However regarding MRI for headaches without any neurologic signs on physical examination or symptoms suggestive of a tumor (e.g. projectile vomiting), the chance of finding a brain tumor are extremely remote. I recall the sad case of a 25 year old son of a physician who had a CT scan with iodine contrast to investigate his headaches. The young man died of an allergic reaction to the dye after having a normal CT head scan.
    #8. “Hundreds of thousands of doctors, both PCP’s and specialists vary widely in capability, while the resources available to the average person to distinguish between the good and not so good are woefully inadequate at best. Personally, I wouldn’t assign much credence at all to patient satisfaction surveys because so many patients evaluate doctors on the three A’s – affability, availability, and last and least, ability. Give me good cognitive and diagnostic skills along with good communications skills and reasonable availability. While affability is nice, I’m even willing to tolerate a certain amount of arrogance if he or she can treat my medical issues skillfully and efficiently.”
    True, physicians vary in capability. The current system does not measure a PCPs ability to optimize the overall value of care delivered. With Doctor Managed Care, the data would be available to make such comparisons. However, I don’t claim that different people would come to the same conclusions about individual PCPs, it is not a one size fits all plan.
    #9. “I’m also not comfortable cutting insurers out of the medical decision making loop. Doctors and hospitals have been known to commit fraud including billing for treatments never performed and putting patients through unnecessary treatments to drive revenue. Insurers have sophisticated data analytics capability to catch a lot of this.”
    Overall, insurers have been powerless to control rampant inflation in health care costs, and medical administration that is largely insurance company driven consumes 31% of health care costs (> $800 billion in 2010). Most fraud is committed by specialists. I would rather have PCPs that know their patients and see the specials’ bills monitoring for fraud, inefficiency, and overcharging than private or public insurance bureaucrats.
    #10. “Additionally, notwithstanding the possible conflicts that you mentioned in earlier comments, I would be more than willing to at least give a Federal Health Board a chance to make judgments about treatments that we should probably not pay for because they are not cost-effective. If the patient still wants such treatments, he or she can self-pay.”
    See my additional comment in response to Maggie.
    Thank you both for the feedback.

  18. David–
    You are right that we do have comparative effectiveness information that is not used. But that, I think will change–very soon.
    Medicare is running out of money and the nation is heading into a long, deep recession/depression. As a nation, we can no longer afford to pay for ineffective treatments.
    The Century Foundation’s Working Group on Medicare (made up of some of the most highly regarded physicians and public health experts in the country) is unanimous in believing that Medicare should begin using comparative effectiveness information to steer patients and doctors to the most effective care.
    The Group doesn’t think that Medicare will begin saying “no” to existing treatments that are popular (even if ineffective) but that it will raise co-pays and lower the fees it pays doctors for services which, the evidence shows, are not effective for patients who fit a particular profile.
    Meanwhile, it will lower-co-pays and raise fees for the most effective treatments.
    When it comes to new treatments, Medicare is likely to want more evidence before rubber-stamping every new drug and procedure that comes along.
    As head of OMB Peter Orszag will have a direct influence on health care policy, and he, along with Senator Baucus and President Obama all believe in the importance of using comparative effectiveness reserach.
    This is (as you acknowledge) not one-size-fits all medicine.
    In the UK the majority of the public is satisifed that NICE is doing a very good job. (You can search NICE–I’ve reserached it, and written about it )
    As for the claim that so many patients die each year because they didn’t get some treatment that they think they want . . .there is no way to calculate what would have happened if a patient had recieved particular treatment.
    But we do know that patients, their families, and sometimes doctors who favor a particular treatment (for whatever reason) frequently exaggerate the likelihood that X or Y would have saved the patient. Very often, those extreme end-of-life treatments give the patient a few more months of low-quality life–at most.
    Moreover, in the U.S. over-treatment injures and kills a great many patients. We have a couple of decades of evidence from Dartmouth that 1/3 of our health care dollars are wasted on unnecessary, ineffective, unproven adn sometimes unwanted treatments.
    Finally, of course it is possible to create an
    unbiased board. There are many, many physicians and medical ethicists in this country who do not take money from the for-profit health care industry.
    Will every decision that board makes me perfect? No– and as new information comes in, it may change its mind (as NICE does)
    But a board made up of highly qualified medical experts, collaborating to try to come to the best decision possible, based on the available evidence, would be greatly preferable to leaving deicisions up to individual phyaisican, some of whom take gifts and fees from manufacturers, some of whom have a financial interest in a particular device or surgical procedure; many of whom don’t keep up with the literature; and 1/4 of whom graduated in the bottom quarter of their med school class.

  19. Dr. Cundiff,
    At the end of the day, I think my fundamental issue with your approach to healthcare reform, at least from a patient’s perspective, is that it vests too much power in PCP’s. The idea of a single PCP or a small group deciding what is and what isn’t covered and controlling access to specialists just feels too constricting, especially since there is likely to be a sizeable variance in the capabilities among PCP’s as well as plenty of natural turnover in the PCP-patient relationship due to retirements, relocations, illness, personal chemistry and other factors.
    At the same time, I like your idea of robust cost and quality transparency tools being available to PCP’s so they can help patients choose the most cost-effective providers, and we should be able to develop ways to reward primary care doctors for this function. Personally, I would like to see all healthcare utilization of each individual tracked via a smart card or similar device like Taiwan does. We could compare the total utilization and health outcomes of each PCP’s patient panel adjust for risk, reward the most cost-effective PCP’s and inform patients who the most cost-effective PCP’s are as well as which specialists and hospitals they choose to refer their patients to. The medical home concept would probably fit well with this approach though it would probably work better if doctors were organized into large groups.
    The Federal Health Board could vary patient cost sharing depending on how cost-effective a given test, procedure, drug or device is deemed to be. For the least cost-effective treatments, we should just not pay for them at all. To take a high cost example, if I have prostate cancer and I want proton beam therapy because it has slightly fewer side effects than standard radiation or seed implantation but costs 5 times as much, I should probably be expected to pay the incremental cost above standard radiation or seeds myself. If I couldn’t afford to pay but a wealthier person could, so be it.

  20. Maggie’s excellent points are numbered:
    #1. You are right that we do have comparative effectiveness information that is not used. But that, I think will change–very soon. Medicare is running out of money and the nation is heading into a long, deep recession/depression. As a nation, we can no longer afford to pay for ineffective treatments. The Century Foundation’s Working Group on Medicare (made up of some of the most highly regarded physicians and public health experts in the country) is unanimous in believing that Medicare should begin using comparative effectiveness information to steer patients and doctors to the most effective care.”
    Let’s give The Century Foundation’s Working Group on Medicare a test. Please forward my evidence-based analyses that have been published in the peer-reviewed medical literature over the past seven years. In each case, these analyses conclude that the treatment hurts or doesn’t help patients and costs a lot of money. In most cases, the elite medical journals (New England Journal of Medicine, JAMA, Lancet, BMJ, etc.)—all funded by drug companies and other special interests—rejected the articles without comment. In all but a few cases, no one from the medical academic community sent feedback letters to rebut my data, methodology, or conclusions. Full disclosure: I lost my California medical license over my discontinuing warfarin (Coumadin, a blood thinner or anticoagulant) in an alcoholic man with advanced tuberculosis, liver failure, and anemia. In my judgment, the risk of him bleeding to death was greater than him dying of blood clots in his lungs. He died of blood clots in his lungs.
    1. Cundiff DK. Anticoagulants for Non Valvular Atrial Fibrillation (NVAF) – Drug Review. Medscape General Medicine. 2003;Available at: http://www.medscape.com/viewarticle/448817. This evidence-based review of warfarin (Coumadin) as stroke prevention for atrial fibrillation concludes, “Given the risk and cost of warfarin and its unknown efficacy compared with aspirin, aspirin should be preferred over warfarin in NVAF.” Roughly, 15,000 – 20,000 Americans have major bleeds into their brains and about 8000 – 10,000 die of bleeding each year due to treatment with warfarin for this indication.
    2. Cundiff DK. Commentary – Insufficient Evidence Supporting Low-Intensity Warfarin for Venous Thromboembolism (VTE) Prophylaxis. Medscape General Medicine™. 07/02/2003; http://www.medscape.com/viewarticle/457570. This was a commentary about an NIH-funded study called PREVENT, testing whether low dose warfarin should be continued for life in patients with one spontaneous (idiopathic: i.e., not associated with surgery or other temporary risk factor) incidence of a clot in the leg (deep venous thrombosis). The New England Journal of Medicine published the study and refused to publish my commentary or even a letter to the editor about it. After the commentary was published in Medscape General Medicine, I asked the principle investigator, Dr. Paul Ridker and the NIH monitor, Dr. Yves Rosenberg, to submit a rebuttal to Medscape. They refused. At the NIH, I appealed up the chain of command to Dr. Elias Zerhouni, the director. Dr. Zerhouni told me that NIH scientists and academic researchers involved with NIH funded trials did not have to respond to criticisms of the methodology or conclusions of their studies. New York Times reporter Denise Grady, who mischaracterized low-intensity warfarin for idiopathic VTE patients as “cheap and safe,” refused to mention my commentary or call the investigators for a rebuttal.
    3. Cundiff DK. Anticoagulation Therapy for Venous Thromboembolism. MedGenMed. September 9, 2004;6(3): http://www.medscape.com/viewarticle/487577 This review concluded, “Anticoagulants have not been shown to be efficacious in reducing morbidity and/or mortality or safe in VTE (venous thromboembolism, i.e., clots in the legs or lungs) treatment.”
    4. Cundiff DK, Manyemba J, Pezzullo JC. Anticoagulants versus non-steroidal anti-inflammatories or placebo for treatment of venous thromboembolism. The Cochrane Database of Systematic Reviews. 2006;Issue 1. Art. No.: CD003746. DOI: 10.1002/14651858.CD003746.pub2. Abstract available at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003746/frame.html, This paper reviewing the same topic as #3, published in arguably the gold-standard of evidence-based medicine journal, concluded, “Only two small studies with a total of 113 participants treated over three months were identified, which gave inconclusive results. Since the use of anticoagulants is widely accepted in clinical practice, designing and implementing other similar studies would not be ethical.” The difference in conclusions resulted from the Cochrane editor and peer-reviewers (4 /7 of which had undisclosed financial conflicts with anticoagulant producing drug companies) rejecting the discussion and conclusions of the authors and writing their own.
    5. Cundiff DK. Evidence-based Medicine and the Cochrane Collaboration on Trial. MedGenMed. June 12, 2007;9(2): http://medgenmed.medscape.com/viewarticle/557263 This commentary details my grievance with the Cochrane Peripheral Vascular Disease Group over the biases concerning #4 above. No one from Cochrane or elsewhere rebutted the commentary. My formal complaint to the Cochrane Disputes Editor, filed in September 2006, has not been addressed.
    6. Cundiff DK. A Systematic Review of Cochrane Anticoagulation Reviews. Medscape Journal of Medicine. January 6, 2009; http://www.medscape.com/viewarticle/584084 This article reviews 58 Cochrane anticoagulation reviews and concludes, “The efficacy and safety of anticoagulant drugs for 30 government regulatory agency approved and off-label indications are in question. At a minimum, 50,000 people have fatal bleeding episodes each year worldwide due to anticoagulant treatment or prophylaxis for these indications. An objective, transparent reassessment of the evidence base of all indications for anticoagulant use (regulatory agency approved and off label) should be carefully done by the government regulatory agencies, including the FDA in the United States and The Medicines and Healthcare products Regulatory Agency (MHRA) in the United Kingdom.
    7. Cundiff DK. Coronary artery bypass grafting (CABG): reassessing efficacy, safety, and cost. Medscape General Medicine. 2002;4(2): http://www.medscape.com/viewarticle/434471 This review challenges the evidence-basis of CABG: “Primary care physicians, cardiologists, and cardiac surgeons have explicitly or implicitly told patients with advanced CAD (coronary artery disease) that with CABG, their angina would be less and their survival chances would be improved. Their decisions about whether to proceed with CABG usually hinged on the belief that these benefits require increasing blood flow in the coronary arteries with surgical revascularization. However, there is no proven cause-and-effect relationship between revascularization and palliation of angina or survival benefit in high-risk groups.” Renowned heart surgeon Dr. Denton Cooley’s commentary about this article concluded, “Clearly, the techniques currently employed may not be infallible and may be too costly when compared with no treatment at all. But neither has nonsurgical or so-called “medical” treatment alone been irreversibly effective, even with the continued introduction of new drugs and revised advice from physicians. In this light, it is just as well to press on with further improvements in techniques for revascularizing the ischemic myocardium.”
    8. Cundiff DK. Thrombolysis for Acute Myocardial Infarction: Drug Review. Medscape General Medicine [TM]. 2002;4(1): http://www.medscape.com/viewarticle/414942 This review of “clot-busters” as treatment of heart attacks concludes, “The theoretical basis of thrombolysis (ie, the open-artery hypothesis) does not account for survival differences in randomized studies. Results of randomized trials of thrombolysis in AMI (heart attack) may have been confounded by lack of uniform use of aspirin, higher control group AMI mortality than prevalent today, and psychological influences due to lack of blinding in some studies. AMI registry statistics do not support the efficacy of thrombolysis in AMI. The NRMI-2 registry (drug company funded and controlled registry) suggests that a significant percentage of suspected AMI patients may be inappropriately receiving thrombolytics.
    9. Cundiff DK. Benefit of Clopidogrel for Acute Coronary Syndrome and Percutaneous Coronary Interventions in Doubt Due to Rebound Adverse Events. American Journal of Cardiology. 15 July 2008;102(2):248 This commentary about an article published in the American Journal of Cardiology concludes, “While this retrospective observational study requires confirmation with prospective randomized trials, the almost doubling of adverse events over a 3 month period possibly due to rebound hypercoagulability means that deaths and acute myocardial infarctions are not proven to be reduced by clopidogrel without follow up event data after stopping clopidogrel. Given that, according to this meta-analysis, clopidogrel increases the major bleeding incidence by 1.5%/13 months (i.e., 15 additional bleeds out of 1000 patients treated), dual antiplatelet treatment carries significant additional risks but no proven benefit. Food and Drug Administration approval for acute coronary syndrome should be re-evaluated based on new trials with follow up event data for at least 90 days after discontinuation of clopidogrel.” In layman’s terms, Plavix, which grossed about $6 billion in 2008 is not evidence-based to work. The problem is that all the trials stopped collecting adverse event data when the drug was stopped, missing the significant number of deaths and heart attacks and other adverse events due to rebound clotting caused by stopping the drug.
    Most of my challenges to medical establishment endorsed, insurance covered medical tests and treatments have not been published in peer-reviewed medical journals. If The Century Foundation’s Working Group on Medicare finishes investigating these nine very inconvenient articles for drug companies and medical special interests, I have plenty more.
    #2. “The Group doesn’t think that Medicare will begin saying “no” to existing treatments that are popular (even if ineffective) but that it will raise co-pays and lower the fees it pays doctors for services which, the evidence shows, are not effective for patients who fit a particular profile. Meanwhile, it will lower-co-pays and raise fees for the most effective treatments. When it comes to new treatments, Medicare is likely to want more evidence before rubber-stamping every new drug and procedure that comes along.”
    Given that actuaries calculate that Medicare will be over $32 trillion in the red in 75 years, this approach is underwhelming to me. I still think the decisions about insurance coverage for individual interventions for individual patients should be made by PCPs accountable their patients individually and as a group. Boards of medical experts, well meaning honest and brilliant as they may be; will try and fail to be simultaneously accountable to politicians, medical special interests, small and large businesses, current patients, and future generations.
    #3. “As head of OMB Peter Orszag will have a direct influence on health care policy, and he, along with Senator Baucus and President Obama all believe in the importance of using comparative effectiveness research. This is (as you acknowledge) not one-size-fits all medicine.”
    Let’s be clear. When comparative effectiveness studies and other scientific evidence serve as the basis for a national board or other top down group of experts to determine the insurance coverage for an individual patient for a particular medical intervention, this is one-size-fits-all medicine. When an individual PCP uses comparative effectiveness studies and other evidence—anecdotal, social, observational or whatever—to decide the insurance coverage for his/her individual patient, that is medicine that can inspire the confidence of most if not all of that PCP’s patients. Additionally, when that PCP by promising not to fund non-beneficial tests and treatments and instead to expand covered services to include paying family and friends to care for their disabled loved ones in their own homes, that PCP will probably attract and retain all the patients he/she needs or wants. Alternatively, individual PCPs who waste medical resources on tests and treatments that are not evidence-based to be beneficial (e.g., #1 – #9 above) will probably be less popular with their patients and may risk losing them. A whole new type of comparative effectiveness research will be spawned that compares the insurance coverage decision patterns of PCPs with excellent clinical outcomes and high patient popularity ratings with the practice patterns of PCPs with lesser results. Positive practice changes will surely result from these kinds of studies.
    #4. In the UK the majority of the public is satisfied that NICE is doing a very good job. (You can search NICE–I’ve researched it, and written about it)
    The USA and the UK are quite different countries. In my training in the UK in pediatrics, oncology, and hospice medicine, I noticed, as have others, that patients are much less questioning of medical authority than here in the USA. About 60% of medical school graduates—frequently the superior students—become general practitioners. People refer to their GP as their “doctor” and specialists at their “consultants.” Specialists spend many years in training to win a consultant post anywhere in the country where they will look after a patient population defined by government bean counters. The UK is not ridiculously overpopulated with specialists as are many areas in the USA. In general, the greater the oversupply of specialists the more is the tendency to perform unnecessary tests and treatments. Compared with the UK, the imbalance of generalists to specialists here is out of control. Many people have no primary care home and rely entirely on specialists.
    In reading your previous posts about NICE in the UK, I see that drug companies appealed a NICE ruling against the use of memory pills for Alzheimer’s disease patients and NICE won. That inspired me to Google, “NICE guidelines legal challenges.” There were 869,000 hits. Just in the first few hits, I found that legal challenges to NICE guidelines are being mounted for osteoporosis drugs, chronic fatigue/myalgic encephalitis treatments and benefits, borderline or anti-social personality disorder treatments, population screening for mental illness, schizophrenia treatments, and breast cancer drugs. Compared with the USA, the UK is not very litigious. With a “National Board of Medical Experts” deciding on what medical interventions to cover here in the USA, the federal justice department will be doing little else but defending its top-down medical rationing decisions.
    #5. As for the claim that so many patients die each year because they didn’t get some treatment that they think they want . . .there is no way to calculate what would have happened if a patient had received particular treatment.
    But we do know that patients, their families, and sometimes doctors who favor a particular treatment (for whatever reason) frequently exaggerate the likelihood that X or Y would have saved the patient. Very often, those extreme end-of-life treatments give the patient a few more months of low-quality life–at most.”
    You might be surprised at what some people would do for the possibility of a few more months of low-quality life. By practicing medical oncology in Canada and the USA and directing a cancer and AIDS pain and palliative care consultation service in an academic teaching hospital for nine years, I know plenty about end-of-life futile and extremely uncomfortable treatments. As long as the oncologists decide what tests and treatments to recommend to patients and then order those tests and treatments, we will have more of the same. When PCPs become the deciders of medical insurance coverage and pick the oncologists that they refer patients to and have to be convinced by those oncologists about treatment decisions, things will change.
    #6. “Moreover, in the U.S. over-treatment injures and kills a great many patients. We have a couple of decades of evidence from Dartmouth that 1/3 of our health care dollars are wasted on unnecessary, ineffective, unproven and sometimes unwanted treatments.”
    As you know, the Dartmouth team arrived at the >30% estimate of waste in our medical system by comparing the cost to Medicare for similar patient populations in different parts of the country. As far as I could find in their publications, they did not categorically challenge any particular medical test or treatment. They assumed that all medical guidelines endorsed medical interventions are valid. Their estimate of waste relates to price gouging, multiple consultants, redundant tests, inefficient administration, etc. For instance, for acute myocardial infarction, they did not categorically challenge doing emergency angiography, angioplasty with or without stents, bypass surgery, thrombolysis (clot busters) which are the biggest expenses of treating people with heart attacks. They just said that patient outcomes in high technology utilization areas were no better than in low technology utilization areas. What is a clinician supposed to do with that information in relation to treating an individual patient? To achieve cost effective quality care, an accountable medical decision maker needs to challenge the use of non evidence based expensive high tech tests and treatments on behalf of patients, individually and collectively. As a practical matter, that decision maker needs to be the PCP rather than the federal board of medical experts and ultimately the courts.
    #7. “Finally, of course it is possible to create an unbiased board. There are many, many physicians and medical ethicists in this country who do not take money from the for-profit health care industry. Will every decision that board makes be perfect? No– and as new information comes in, it may change its mind (as NICE does) But a board made up of highly qualified medical experts, collaborating to try to come to the best decision possible, based on the available evidence, would be greatly preferable to leaving decisions up to individual physician, some of whom take gifts and fees from manufacturers, some of whom have a financial interest in a particular device or surgical procedure; many of whom don’t keep up with the literature; and 1/4 of whom graduated in the bottom quarter of their med school class.”
    It would be possible to create an unbiased board, and it would be possible to create a technologically competent board. I challenge that it would be possible to create an unbiased board that is technologically competent. For instance, have The Century Foundation’s Working Group on Medicare propose a few names of unbiased but qualified oncology experts to be on the board to decide reimbursement for cancer drugs. Who will vet these experts? Since I’m board certified in medical oncology, could I be appointed to this proposed board over the objections of drug companies and practicing oncologists? As a researcher and director of a cancer and AIDS pain management consultation service, I have accepted lecture honoraria from three different drug companies that make competing opiate drugs for cancer pain treatment. Would that disqualify me from serving on a board to decide the most cost effective and best treatment of cancer pain? What if some group mounted a court challenge of my federal board endorsed recommendations for morphine use in metastatic lung cancer, saying the recommended doses were too high and amounted to physician assisted suicide or that they were not cost effective? The complexities are mind boggling……
    Now to Barry’s points:
    #1. “At the end of the day, I think my fundamental issue with your approach to healthcare reform, at least from a patient’s perspective, is that it vests too much power in PCP’s. The idea of a single PCP or a small group deciding what is and what isn’t covered and controlling access to specialists just feels too constricting, especially since there is likely to be a sizeable variance in the capabilities among PCP’s as well as plenty of natural turnover in the PCP-patient relationship due to retirements, relocations, illness, personal chemistry and other factors.”
    My proposal is about as consumer directed as you can get. You can vet the available PCPs in your area before choosing one. As patients of a PCP, you can individually or collectively give your PCP your feedback about your health care priorities. You can volunteer to be on a patient committee that reviews insurance denials of your PCP and decides whether to grant variances. You can read annual reports of your PCP’s practice and utilization of the insurance allocation and compare it with that of competing PCPs and give your input. You can change PCPs, if you find one that you like better. I am open to including other patient safeguards.
    #2. “At the same time, I like your idea of robust cost and quality transparency tools being available to PCP’s so they can help patients choose the most cost-effective providers, and we should be able to develop ways to reward primary care doctors for this function. Personally, I would like to see all healthcare utilization of each individual tracked via a smart card or similar device like Taiwan does. We could compare the total utilization and health outcomes of each PCP’s patient panel adjust for risk, reward the most cost-effective PCP’s and inform patients who the most cost-effective PCP’s are as well as which specialists and hospitals they choose to refer their patients to. The medical home concept would probably fit well with this approach though it would probably work better if doctors were organized into large groups.”
    All of these things that you like depend on individual PCPs being the decision makers for their patients.
    #3. “The Federal Health Board could vary patient cost sharing depending on how cost-effective a given test, procedure, drug or device is deemed to be. For the least cost-effective treatments, we should just not pay for them at all. To take a high cost example, if I have prostate cancer and I want proton beam therapy because it has slightly fewer side effects than standard radiation or seed implantation but costs 5 times as much, I should probably be expected to pay the incremental cost above standard radiation or seeds myself. If I couldn’t afford to pay but a wealthier person could, so be it.”
    See the above discussion about the problem with a Federal Health Board. Either the Federal Health Board with possible appeal to the courts or the individual patient’s PCP needs to be the insurance coverage decision maker. It can’t be both.

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