Hardly a Fatal Blow: Everything You Read About Now Is Foreplay

We knew that the Senate Finance Committee would reject the public sector option. Now they have done just that.

This is not news. Nor is this a “fatal blow” for progressives.

Will the public option survive a vote on the Senate floor?  Probably not—though it could happen. But this still does not mean that the public option is dead.

We know that the bill that emerges from the House will contain a MedicareE (for Everyone) alternative. The House bill and the Senate bill will then go to conference. This is the moment that matters. As a respected HealthBeat reader who knows Washington well recently told me, “Everything else is foreplay.” Much of what we are reading now is posturing–by some politicians ( Charles Schumer deserves an Emmy), by some pundits and by unnamed sources who want reporters to think that they know more than they actually know.

I would be happier if I thought both the Senate and the House bill would include a public option. But that isn’t necessary. All that is necessary is to get a bill through the House, and a bill through the Senate, with or without MedicareE. In Conference, where the two bills are merged, they can put the public option back in.  

As former Congressional staffer and HealthBeat reader Jim Jaffe points out:  “Remember that the Clinton bill never came to a vote in either House, so there was no chance to duke out differences in conference. Here it appears probable that each bill will pass a bill, however imperfect they may appear. I'd call that progress.”  Keep in mind: once the bill goes to conference committee they won't need 60 votes in the Senate. It will be purely an up/down vote.

But isn’t Senate Finance the stronger committee? In conference won’t the Senate trump the House?  Traditionally, Senate Finance has wielded great power. But in the past, it was chaired by legendary power brokers: Russell Long. Bob Dole. Lloyd Bentsen.

Max Baucus is no Lloyd Bentsen. He set out to put together a “bi-partisan bill,” and he has failed dismally. To be fair, from the beginning this was a hopeless task: the conservatives do not want reform of any kind. But Baucus should have known that.

The conservatives prefer the status quo. Many are willing to give every native-born American a piece of paper titled “insurance”—but, as I noted here, they would leave it to the insurance industry to decide what that piece of paper is worth. Its value would depend on what the customer is able and willing to pay. If the customer can’t pay roughly $13,500 (in today’s dollars) for a family plan, earns too much to qualify for a government subsidy (for example, a couple earning over $58,820) and doesn’t have an employer willing to pick up roughly 75% of the premium, he and his family will probably wind up with a high-deductible plan that they can’t afford to use. They may be able to get primary care without meeting the deductible—if they can find a primary care doctor. Bottom line:  “Reform” would mean that we continue to ration care according to ability to pay.

Low-income households would be covered by subsides, but many on the third and fourth steps of a five-step income ladder would find themselves spending 12% of their income for such “coverage” as the private insurance industry decides to give them. For a family of three with joint income of $80,000, that means they could wind up paying $9,600 in premiums, plus up to $10,000 a year, out of pocket, in co-pays and deductibles.

President Obama and White House budget director Peter Orszag understand that if health insurance isn’t affordable, reform becomes a sham. The political penalty for promising what you can’t deliver would be steep. Thus they understand that for health care reform to work they must do what Massachusetts didn’t do: reduce the cost of care before rolling out full coverage.

The Commonwealth Fund estimates that administrative savings alone would make a public-sector family plan $2000 less expensive than a private-sector plan. And that’s just the beginning.  Reform could save billions if some of the Medicare reforms currently under consideration are put in place over the next three years–and then incorporated in the public plan. By paying  doctors and hospitals more if they collaborate to provide the  effective, efficient, patient-centered care that we see at medical centers like Geisinger and Mayo —while refusing to pay for  unnecessary tests, preventable readmissions, and over-priced products and services that expose patients to risk without benefit—reformers could drive premiums lower. In order to compete, many private insurers would almost certainly follow suit.

Many in the administration know what needs to be done. Medicare just needs to be begin implementing the structural changes that the Medicare Payment Advisory Commission (MedPAC) has been recommending for years—reforms that did not interest President Bush because he was engrossed in a pet project: turning Medicare over to the for-profit industry.

What will happen in Conference? Today the Wall Street Journal said it all in one sentence: “The idea could still revive if the White House weighs in strongly on its behalf.”  As I have said in the past everything depends on what President Obama, Peter Orszag and Rahm Emanuel decide to do. Forget what Schumer or Snowe or even Rockefeller say today. The deal will be consummated, not on the Senate floor but in conference. Is the White House divided on this issue?   Perhaps. But it is hard to see how the administration is going to deliver health care for all unless, in the end, the President insists on a public plan that, together with Medicare, will have the clout to begin eliminating the waste in our health care system.

48 thoughts on “Hardly a Fatal Blow: Everything You Read About Now Is Foreplay

  1. Yes Obama,Orsag and Emanuel are key.
    Maggie-What impact, if any, will vox populi have especially if they take to the streets? Or engage in civil disobediance sit-ins at corporate headquarters of Big Insurance and Big PhRMA?
    (60s redux)
    Dr. Rick Lippin
    Southampton,Pa

  2. Rick–
    I think we need sit-ins at Pfizer.
    But I don’t see that happening . . .
    Part of the problem is that there is no obvious constituency — during the civil right movement African-Americans provided a clear constituency.
    Today, the majority of Americans, who have insurance, don’t realize that they are over-paying for being over-treated.
    And the uninsured–who are mainly poor– don’t have a powerful voice and
    are not united. (Poor whites don’t identify poor blacks; poor people in rural areas do not identify with poor people in Detroit, etc. etc. )
    Finally, and most importantly, health care is so complicated–and the whole issue has been so confused by truly terrible reporting– not just in the mainstream meda, but also, sadly, in some parts of the blogsphere –that most Americans have no idea what they should be protesting FOR.
    Relatively few understand what a public option would mean–or what it would mean if Medicare could negotiate for discounts on drugs.
    Sadly, the single-payer moovement has persauded many that the only demon is private insurers–ignoring the fact that private insuers are just passing on the cost of sky-rocketing health care bills in the form of higher premiums.
    Ideally, private insurers would have reined in those costs rather than passing them on.
    But they weren’t smart enough to do that. And they don’t care enough about their customers; they care about their shareholders.
    Shareholders prefer that health care costs keep rising so that more money flows through the private insurers.
    So there we are.
    But– this debate will be continuing for at least another 3 years.
    Perhaps, over that time
    enough people will be able to tell the public the truth that there will be enough people out there to
    demonstrate for what we truly need:
    Fewer tests, fewer procedures, fewer over-priced drugs.
    Less profit-driven medicine.
    But it’s a very hard message– counter-intuitive and runs against the grain of what Americans
    believe: More is always is Better.
    Enough is Never Enough.
    “Plenty” Doesn’t Count.

  3. Maggie – You state above, “By paying doctors and hospitals more if they collaborate to provide the effective, efficient, patient-centered care that we see at medical centers like Geisinger and Mayo —while refusing to pay for unnecessary tests, preventable readmissions, and over-priced products and services that expose patients to risk without benefit—reformers could drive premiums lower”
    In your view, what would be the outcome if a public option failed to materialize but Medicare implemented those reforms for the Medicare population anyway? In particular, would the response of hospitals and physicians create new and more efficient delivery mechanisms that could then become attractive to insurers outside of Medicare simply because they cost less? Similarly, would Medicare, with its larger subscriber base and their greater utilization of services per capita, have greater clout to make a difference than a public option as currently proposed, particular as limited to a rather small segment of the population?
    Without suggesting that the public option would be irrelevant (it would be very welcome if achievable), would it be less of a force than Medicare if the latter fully exploited its leverage to constrain healthcare system costs?

  4. may the perp weigh in here? If there were massive support for radical reform, sit ins hither and yon would be a great idea. There isn’t such support. At this point they’d be little more than a signal of frustration and impotence.
    Fred Moolten has basically described what Medicare Advantage purports to be. The government pays a flat fee to the insurer, who stands to profit if less is done or things are done more efficiently. You can argue about whether it works that way (and the fact that it shouldn’t be above the average medicare payment per capita is beyond argument), but that’s the theory. unless you want the government to micromanage on efficiency issues,which some of us find less than attractive, how would you encourage such efficiency?

  5. Fred-
    My concern is that if Medicare begins to really cut back on hazardous waste, many more doctors will refuse Medicare.
    Few hospitals will be able to afford to refuse Medicare.
    But physician-owned surgery centers may well turn them away
    .
    (These physican-owned centers can charge loyal patients more while cherry-picking the easiest patients.)
    Finally–and this is truly unfortunate–a great many doctors don’t like caring for older (over 65) patients.
    They tell me that these patients complain about things that cannot be helped (the aches and pains of aging. And here aome doctors are no doubt right. Many Americans have been taught to feel that a “good doctor” should be able to solve all of their physical problems. The fact is that, as we age, when we wake up in the morning, we don’t feel the way that we did when we were 25—or even 35.
    Doctors also say that older patiients are time-consuming. If they are retired, they have plenty of time, and demand too much of the doctor’s time. (I’m sure this is true is many cases. Some older patients are simply lonely. In other cases the patient really does need a doctor who has time to listen to him and talk to him.
    Bottom line: I’m not convinced that Medicare can continue to have the market clout that it now has unless there is a public plan for people under 65 that can join ranks with Medicare.
    Medicare could wind up being like Medicaid, while
    wealthier seniors buy a public sector plan.

  6. Maggie – You may be right, and if a public option passes, we won’t have to find out. On the other hand, it unfortunately may not. In that case, how would you rate the possibility that the political clout of seniors (likely to increase even further as the population ages) would be sufficient to make it difficult for too many physicians to slight them without discovering that Congress would find ways to discourage that practice?

  7. “My concern is that if Medicare begins to really cut back on ‘hazardous waste’, many more doctors will refuse Medicare.”
    If Medicare fees get cut substantially, many doctors will find it un-economical to take care of Medicare patients. At that point, physicians have the option of “non-paring” with Medicare. That doesn’t necessarily mean that they won’t see Medicare patients, it just means that they don’t accept Medicare fees as full payment for their services and bill the patients directly. The patient then needs to pay the doctor directly and submit the bill to Medicare.
    From a physician’s perspective, this is a double-edged sword. It can increase reimbursement and cut billing costs/effort, but it runs the risk of alienating and driving away patients. From the patient’s perspective, it is a pain; not only is the doctor likely to be charging a higher fee that what Medicare covers, but the patient needs to deal with the paperwork, front the money and wait for reimbursement. From the Government’s perspective it is a massive headache, in addition to calls and letters from angry seniors, the Government will have to deal with massively increased claims processing costs – Medicare claims tend to be batch processed electronically when submitted by physicians/billing companies.
    There is another trend that is catching on as well – “non-paring” with all insurance and/or “going boutique”. In both of these cases, the physician stops accepting “assignment” and bills the patient directly AND expects direct payment from the patient – sometimes at the time of service. Sometimes there is an upfront payment or retainer. If you go to various physician blogs such as SERMO, you will find much discussion of this topic.
    One of the things that I think you don’t fully understand is how much of a pain it is to deal with insurers – actually in our experience Medicare is probably the best of a bad bunch. The number of hours a physician (and that physician’s office staff) spends dealing with insurance companies can be astonishing. The number of B.S. excuses insureres use to avoid payment is legendary, the level of medical knowledge of many of their staff is abysmally low and in many cases their penalty for late or non-payment is better profits. United Healthcare is particularly hated by many doctors.
    There are many testimonials from physicians who have gone “boutique” or stopped “paring” with any insurance. Many tell a similar story; at first they lose patients, but don’t lose nearly as much money since they earn more per patient they see and can cut billing costs dramatically. They have more time to spend with patients and they feel more satisfied with their work. The patients also like it better since the docs have more time to spend with patients. Eventually, some patients come back and they end up as well or better off financially, but feel more satisfied with how they practice.
    This model of practice is probably not for everyone and probably won’t work in every market, but I think it will become more common in the future. I don’t think it will work in my specialty, but do think it will work for a lot of primary care docs. If my Internist told me he was going “boutique”, I would stay with him and pay his charges – and I wouldn’t begrudge it.
    “Finally–and this is truly unfortunate–a great many doctors don’t like caring for older (over 65) patients.”
    As for not liking older patients – I hadn’t heard that. My own personal experience is that I prefer older patients, although people are people and there are nice one and annoying ones of all ages.

  8. What if the Dems pass a plan and it fails to deliver any real help?
    Then we have a) Dems dont have an answer, b) Repubs dont have an answer.
    This may be the case for many issues as of the 2012 elections. If so, can a third party win?

  9. Maggie, as usual, fantastic post, very insightful — and in this case, comforting; I do hope this wasn’t as fatal a hit as it’s felt for the last couple days. And I really hope you’re right in your appraisal of Max Baucus’s sway come conference-committee-time, because, though he may have been on a misguided, well-intentioned quest for bipartisan compromise, I’m with this blogger http://www.healthprose.org/2009/09/30/baucus-tells-america-no-public-option-horatio-alger-is-role-model/ on this one — Sen. Baucus’s line has been way too Horatio Alger for my taste.
    You, Dr. Rubin (see my prev. link), and the WSJ you referenced, are definitely right that the only way for the reform we need to have a chance is for the White House to take a strong leadership role, one way or another.
    Alison McCauley
    Washington, DC (AmplifyPublicAffairs.net & DisruptiveWomen.net)

  10. jim-
    You agree that, under Medicare Advantage, private insurers should be paid no more than traditional Medicare would spend to provide the service.
    We tried that in the 1990s with “Medicare Plus.”
    Private insurers quickly discovered that the vast majority were losing money on Medicare Plus. They just aren’t very efficient and their higher administrative costs are a problem.
    Polls show that the majority of Americans want a public option.
    And yes we do want a national board using comparative effectiveness reserach to create guidelines (not rules) for the most effective care for patients who fit a particular medical profile.
    EVery other developed country has such national boards. The U.S. is the only country where doctors routinely ignore guidelines for best practice. A great many doctors ignore medical evidence. As a result, more than 100,000 patients are harmed each year by medical care.
    If you review how different doctors treat very similar patients you find wide variation that has nothing to do with medical evidence.
    The variation has to do with where the doctor was trained–and whether he has kept up with changes since then. (Some doctors practice the way they did 25 years ago.)
    Whether the doctor is trying to keep a solo practice going in an area where overhead is very, very high. The only way he can bring in enough money is to “do more.”
    Patients are not in a postiion to know whether their doctor is giving them the best care.
    The only person who can judge how good a doctor is is another doctor (or, other medical professinal such as a nurse).
    This is why patients get the best care at large medical centers where docs are looking over each others shoulders, and they are following evidence-based guidlines– the VA
    Kaiser, Mayo.
    They are using the same “comparative effectiveness” reserach that a federal board would be looking at.
    And it is possible to insulate that federal board from lobbyists and Congress–other nations do it.

  11. When you talk about “MedicareE,” you seem to be referring to a form of public option that allows anyone who chooses to do so to buy into Medicare. That would be good news, but it’s much stronger than anything in the original version of HR 3200. My web search isn’t turning up any other reference to “MedicareE” being in the House bill. I’d appreciate more information on this.

  12. @jim jaffe
    “unless you want the government to micromanage on efficiency issues,which some of us find less than attractive, how would you encourage such efficiency?”
    I hear you, but my first thought is, well, how about the EnergyStar system? Personally I think the gov’t should go a lot farther with energy efficiency standards, but regardless, this system of standards has become very mainstream and, arguably, made a significant difference in that marketplace.
    Is this a completely different arena? Of course. And are we talking about a different “genre” of efficiency issues? Sure — though there are similarities (hardware/software/tools efficiency is certainly relevant when discussing healthcare price-tags).
    I guess my point is just that there have been successes in this area, and I actually do think the gov’t could effectively encourage efficiency in the healthcare arena as well. (Comparative effectiveness research and related issues come to mind as well…)
    Alison McCauley
    Washington, DC (AmplifyPublicAffairs.net & DisruptiveWomen.net)

  13. @Legacy Flyer
    Many elements of what you’re saying re: “going boutique” make sense — especially your points about dealing with insurance companies. Besides the toll it takes on physicians’ morale and the amount of time they’re able to spend with patients (which impacts quality of care, I’m sure), think about the market value of physicians’ time, and then the amount of time they have to spend on all that B.S. — I’m sure the $ waste caused by this problem alone would make me want to vomit.
    Still, this problem just makes me feel more strongly that reform is needed in the physician-insurer-patient cost/price-tag/payment system (including, obviously, paperwork and policies/standards for coverage). If/when more physicians and/or medical facilities require up-front payment etc. from patients, it just seems like that ends up widening the gap in medical care options (or lack thereof) for lower- versus higher-income Americans.
    [I’m done now, for real:) ]
    Alison McCauley
    Washington, DC (AmplifyPublicAffairs.net & DisruptiveWomen.net)

  14. Betsy–
    Medicare E is just a name that I and I few others use for “the public sector option” (an awkward and ugly phrase.)
    At this point, it’s pretty well agreed that the “public option” would be modeled on Medicare and the House Bill (which has a long section on Medicare reform) makes it clear that the publilc option would incorporate those reforms.
    The public option won’t be rolled out until 2013, so that gives Medicare 3 years to work on those reforms.
    It won’t be “for Everyone” at the very beginning.
    The first year (2013) the uninsured, the self-employed and people working for very small companies will be able to go to the Insurance Exchange and pick either a private sector plan or the public plan.
    The second year, people who work for somewhat larger (but still not large) companies will be able to go to the Exchange and pick the public plan if they choose.
    Meanwhile anyone who becomes uninsured–even for a brief time– can go to the Exchange and pick a public or private plan.
    And–this is important–even if their circumstances change,, they can stay in the Exchange and stick with the plan they chose.
    Few people have commented on this, but I checked with the House committee.
    A great many Americans are uninsured for some period of time in a given year–in between jobs, or whatever.
    They can go into the Exchange at that point–which opens it to a huge number of people.
    In addition the House bill plans to open the Exchange to Everyone (including people who have employer based insurance through a large corporation) in the future. The Bill doesn’t specifiy when, but I’m told that people are talking about “in 5 possibly 3 years.”
    We need time to figure out how many of those people will need subsidies.
    Right now large employers pay an average of 75% of premiums.
    Without that help many middle-income and lower-income people will need–adn qualify for–subsidies from the government.
    In addition, people who now have insurance through a large employer who is paying an average of 75% of the premium are not, by and large, that eager to go out and buy their own insurance.
    They might find the idea of a public option appealing, but most would prefer to “wait and see” how it works out.
    Best, mm

  15. Legacy, Fred, Joe Says,Alison
    Legacy– Right now it is illegal for doctors to “balance bill” patients on Medicare (i.e. charge them the difference between what Medicare pays and what they want to bill.
    Under reform, I suspect that what you describe–leaving it to the patient to bil Medicare while charging whether the doc feels like charging will be illegal.
    Half of all U.S. seniors have total income of less than $20,000 a year –this includes Social Security,, pensisons, dividends, investment income, part-time work etc.
    They have to be protected against those specialists who would gouge them.
    That said, reform already plans to hike fees for primary care,, geriatricians and pediatricans by 5% to 10%–plus add bonuses for quality.
    Finally, and most importantly, more and more providers are going to be
    joning “accountable care oganizations” where they are on salary, or joining with other doctors and hospitals to accept “bundled payments”
    That’s the future because that’s where the financial incentives will be
    Boutique medicine will appeal to some wealthy patients and very popular docotrs can attract enough patients to do it. But well-heeled patients expect real service from boutiques: typically, they except access to the doctor by phone, e-mail or in person 24/7.
    And they don’t want to talk to someone filling in for him.
    This is a way of practicing medicine that may work for a small subset of society but the quality of care is lower than the care one would recieve in a multi-specailty clinic where docs collaborate across specialists and share knowledge.
    Boutique medicine is likely to thrive in some parts of the Boston to DC corridor, in Florida , in Southern California and some parts of Texas.
    And even then , as well educated people begin to appreciate the accountable care or Mayo model, I suspect it will shrink.
    Fred–
    It’s hard to say how much political clout seniors will have in the future.
    The seniors of the future are Boomers, and younger generations generally dislike Boomers.
    They see us as spoiled and demanding. They resent us: older booomers got the bargains when houses were still cheap; they go jobs when good jobs were still plentiful.
    They broke all the rules (sex, drugs and rock-and-roll) and yet many of them still wound up on top.
    Ideally other generations would give us credit for some things: without the boomers, Americans would still be eating squishy white bread while listening to bubble-gum music.
    (Okay, probably some later generation would have discovered baguettes, home-made bread, Julia Child, yougurt, Sushi, a group of geniuses like the Beetles, and the fusion of black and white music that came in the 1960s . . but it could have taken a long, long time.
    And the Boomers did help move civil rights and womens’ rights forward. They also tried to warn us about fighting guerilla wars in countries where people don’t want us there.
    Nevertheless, most people don’t like us. So I’m not at all confident that younger generations are going to support our right to healthcare . . .
    We will have to stand up for ourselves–and at a certain point, we will be outnumbered.
    My guess is that as they age, boomers are going to find themselves paying much higher taxes than we ever expected.
    Going back to your actual question: Yes, I do think that Medicare reform could have an influence on the private insurance market for those under 65.
    Insurers would love to be able to cut make on health care spending–as long as Medicare provides political cover.
    But patients who don’t understand that they are being hurt by unnecessary care won’t be thrilled about the cuts . . .which may make it hard for private insurers to follow Medicare–unless reformers do a really job of public education.
    Joe Says–
    I don’t see a third party winning any time soon.
    In the future, as the demographics of the country change, and as we see more inter-marriage among different racial groups, we could see a third party arise from a coalition of blacks, Latinos, mixed famlies and immigrants from many parts of the world. Very progressive whites might well be part of the coalition (if they were accepted)
    This would be a party to the left of today’s Democrats, a party that, in all likelihood, would redistribute income (through taxes) to build a social safety net.
    I don’t see this happening anytime soon.
    .
    Allison–
    Thanks for the kind words.
    Yes the time has come for the White House to lead–as it ultimately did during the civil rights movement.
    And when someone brings up Horatio, they’re really saying “everything man for himself.”
    Boutique medicine would only lead to even more sharply tiered health care–tiered by ability to pay.
    Boutique medicine is an impractical model becaues it assumes a solo practioner or very small practice that doesn’t enjoy economies of scale.
    It also encourages over-treatment– it is designed for the “demanding consumer” who knows what she wants when she wants it and and will stamp her little feet until she gets it.
    The doctor becomes the servant of the very wealthy.
    Not, I think, a healthy model.
    I agree that the government can and should establish guidelines in many areas– and comparative effectiveness reaserch is the tool to use when creating guidelines for healthcare.
    Ronald Reagan taught us that government involvement is always bad. We have to get over that idea. The fact is that the postal service works very well. U.S. overnight mail works very well–and is much, much cheaper than Fed Ex.
    The FDA can save lives–if it is allowed to do its job.
    Medicare is a hugely succesful program. In the last 20-25 years it has become increasingly wasteful, but that waste can be eliminated while improving the program.
    .

  16. Regarding whatever “public option” is in House bill –1) will insureds pay premiums — how determined? And 2)local BC/BS, a non-profit type, claims public option will drive them out of the market. True?

  17. Linda-
    The people who are insured will pay the premiums–unless they have an employer willing to share the cost.
    The premiums will be based on what it costs the public plan to deliver care to the average patient in your geographic area.
    Premiums will be the same for everyone, regardless of pre-existing conditions.
    The only exception– insurers will be able to charge older paients twice as much as younger patients . Probably this will also apply to the public plan. (Otherwise the public plan would wind up with no younger customers, and become a very expensive pool.)
    The premiums should be at least $2000 less than a comparable private sector family plan would cost because the public option won’t lobby Congress, pay exeutives 7-figure salaries . . spending a fortune on advertising and marketing.
    If you earn less than 4 times federal poverty ($88,000 for a family of 4) you will qualify for a federal subsidy to help pay premiums.
    Unfortunately, these days most Blues don’t provide customers with very good value for their money (though this varies state to state).
    If you Blue is claiming the public sector plan will put it out of business this is because it fears that the public plan will be able to offer you higher qualtiy coverage at a lower cost to you.
    In this case, it deserves to go out of business.
    Some insurers–particuarly non-profits–will be able to compete successfully with the public plan.
    People like you will decide. No one will be forced to choose the public plan. Everyone will have a choice between the public plan and several private plans.
    But we can’t afford to keep overpaying private sector plans those that can’t offer good value for our health care dolalrs.

  18. To Rick an others-
    As a nurse I am outraged and also very ashamed about our disgraceful HC System and for a few years I’ve felt it was time for civil disobedience. Our profit-driven system wastes so much and harms so many. I wish I’d been part of the sit-in at Aetna in NYC on Sept 29 2009. Many more CD actions are planned across the country.
    Click to view the powerful NYC CD action that re-frames “the message” and advances Medicare E as the policy solution for health reform.
    http://www.youtube.com/watch?v=xOB1zOBr7IM

  19. Ann–
    I agree that civil disobedience would be a great idea.
    When I did the roundtable with Marshall Ganz that I metioned in my last post, he also called for civil
    disobedience to call for true health care reform.
    (It wss a good roundtable, and I thought Ganz was excellent. The young doctor who disagreed with Ganz and I was also very good. (None of us had every met, so this was all
    quite spontaneous.)
    You can see and hear the roundtable here http://www.freespeech.org/video/grittv-september-1-2009

  20. Maggie,
    You say: “The U.S. is the only country where doctors routinely ignore guidelines for best practice.”
    I think it is exaggerated to say that doctors “routinely ignore guidelines” as if all doctors ignore all guidelines. In the first place there are frequently different guideline promulgated by different societies (recommendations for screening mammography as an example). Secondly, guidelines change from time to time and being 6 months late in changing from the old guideline to the new guideline is not the same as ignoring guidelines.
    Presumably you say this because there have been studies showing rates of compliance with guidelines vary in different countries. Can you point me to those studies?
    Finally, I will point out what you have chastized me for saying before – following a guideline without protection from legal consequences is foolish. The essence of defensive medicine is doing test that are not indicated (or recommended by guidelines) in order to protect from lawsuits. You say this doesn’t happen much. I see it every night.

  21. tough talking about guidelines in this pluralistic society. there are a lot of them and I doubt that any follows all, or that it would be possible. one thing the statists are talking about here is elevating a single set of Guidelines that would have near legal status. at that point, of course, they’d be something other than guidelines.
    for those of you enthusiastic about civil disobedience, think it would be a good start to just go to the doctor or other facility, get the care you need and then refuse to pay the bill. that would get their attention in a much more direct way.

  22. to jim jaffe — Re your statement: “for those of you enthusiastic about civil disobedience, think it would be a good start to just go to the doctor or other facility, get the care you need and then refuse to pay the bill. that would get their attention in a much more direct way.”
    Are you serious? Whose attention would this get? If I am uninsured, it will get the attention of a collection agency. If I am insured, then your suggestion does not work.
    Civil disobedience (CD) is about ordinary Americans–caring, ethical people like most of us here on this blog–taking a stand for what’s right. It is not a tactic to be entered into lightly.
    Serious CD actions will be taking place across the U.S. to re-focus the debate where it belongs: on the need for an effective, affordable, and humane healthcare system for all, and on calling out the obstructionist individuals and entities that are the cause of our healthcare crisis and who are spending huge sums of “healthcare doallars” to block needed reform. Support CD actions at http://www.mobilizeforhealthcare.org

  23. Ann Malone, RN
    Serious CD actions will be taking place across the U.S. to re-focus the debate where it belongs: on the need for an effective, affordable, and humane healthcare system for all, and on calling out the obstructionist individuals and entities that are the cause of our healthcare crisis and who are spending huge sums of “healthcare dollars” to block needed reform. Support CD actions at http://www.mobilizeforhealthcare.org
    ———-
    What causes me to rank is the lack of fairness in such a delivery of vital social needs. I can see how prices can vary when you buy Cadillacs or caviar, but why should the price of healthcare in the same community from the same provider be so widespread with those least able to afford high prices systematically being charged those high prices. It seems every other developed country on earth has figured the fairness thing out, but not this country. This unfair fiasco of a system in a critical social area needs to end, but why did it begin here in the first place?
    As an example, I got a Tricare (similar to Medicare) EOB for some test the other day. The hospital charged $240 for the test of which Tricare will only recognize about $40. The difference is written off and the total paid by Tricare and myself (copays) will be $40. Now someone with no insurance or with very poor insurance with high deductibles might well be charged the full $240 and be expected to pay this. How can this be justified in healthcare???

  24. Jim, Legacy, Ann, NG
    Jim– Don’t know where you get your healthcare, but where I get mine you have to pay upfront.
    No credit card (or insurnace care ) when I come in, no care. I also am expected to pay the co-pay Before I see the doctor.
    This is also the case at ERs and outpatient clinics. (At an ER they can turn you away as long as you are capable of walking out the door. That’s the law as clarified during the Bush administration.)
    Legacy– Much has been written about how US docs don’t follow guidelines.
    In a recent Harris poll, physicains themselves rerpoted they don’t follow evidence-based guidelines.
    Only 44% said they follow them consistently, 12% said they are either “planning do so” 12% or “considering doing so” (26%)
    Why don’t they follow guidelines? The belief (often inaccurate) that there are no relevant guidlines; the inconvenience of using them (37%) disgareement with guidelines (33%) and the diagnosis wasn’t clear (48%). (Some docs cited more than one reason.)
    See http://www.harrisinteractive.com/news/newsletters/healthnews/HI_HealthCareNews2008Vol8_Iss4.pdf
    I have also read that younger woman doctors are more likely to follow guidelines.
    Orthopods are less likely to follow guidelines.
    Cardiologists more likely to follow guidelines.
    Ann–
    I believe in well-organized, peaceful civil disobedience.
    But I was very disappointed to go to the website you cited and read that it called for sit-ins at insurance companies because
    “Insurance companies are the real death panels in America. They make billions in profit.”
    The statement went on to say that insurance companies are the “real villians” in the U.S. health care system.
    As readers of this blog know, even the biggest health care insurance companies are barely profitable, showing profit margins of 3%.
    Their stocks have been in the tank for quite a while.
    This is why so many seroius Wall Street investors simply laugh at health care reformers who say things like this.
    Why aren’t they profitable? Insurance companies, like the rest of us, have had a very hard time keeping up with sprialling health care bills as doctors and hostpitals “do more” (more tests, procedures, surgeries) every year, charging more for many of them, and as Americans take more drugs (as a nationa, we’re seriously over-medicated) and pay more for each pill every year.
    Insurers have been passing those spiralling costs along int he form of higher premiums. But they have hard tiem keeping up– their reimbursements to hosptials, doctors and patients have been climbing by 8% a year, each and every year for the past 10 years.
    There is no single “villain” behind health care inflation. .
    But there are many making huge profits on our over-priced health care system. A great many “non-profit” hospitals show huge surpluses,esome
    specialits make $700,000 to $1.5 million or more a year , while Pharma shows 16% profits on its drugs and devices.
    Meanhwile, ealth insurance companies are among the least profitable industries in the U.S.
    (They rank 87th.)
    Yes their CEOs take home huge salaries, but that reprsents s tiny, tney portion of the premium dollars they take in.
    And the CEOS of many non-profit hosptals as well as the CEOs of drug companies, device companies, also haul home exorbitant salaries.
    When health care reformers get their facts completely wrong (or don’t even bother to look at the facts) and ignore the truth that patients, too , are part of the problem — they undermine the credibility of everyone striving for real reform.
    How are patients part of the problem? Consdier the patient who demands an angioplasty for angina that will provide a temporary “quick fix” rather than his changing diet, exericing and taking medication for a long-lasting cures.
    He expects you and I to pay for his angioplasty (higher premiums, higher Medicare co-pays) and whines if a private insurer denies his claim–even those medical evidence shows that the agnioplasty is an ineffective treatment for certain types of angina.
    Finger-pointing, demonizing one part of the health care industry, and lazy thinking makes it so easy for the conservatives who oppose reform to argue that the reformers are naive,childish, and simply have no idea what they are talking about.
    Why am I not suprised that “Healthcare Now! (a single-payer group) is listed first among the organizers?
    Finally, there are many things to dislike about the private insuers: 1) they oppose a public option because they don’t want to share those new customers and 2) most often, rather than saying “no” to that unncessary angioplasty. They say yes, and pass the cost along in the form of higher premiums.
    NG– You are right about the basic lack of fairness.
    But if I’m not mistaken, the House Bill says that hospitals cannot charge uninsured people more than they charge the insured (a group rate than insurance cmpanies have negotiated.)

  25. Maggie,
    You say: “The U.S. is the only country where doctors routinely ignore guidelines for best practice.” You also say: “In a recent Harris poll, physicians themselves reported they don’t follow evidence-based guidelines. Only 44% said they follow them consistently, 12% said they are either ‘planning do so’ 12% or considering doing so’ (26%) (sic).” (Thank you for providing me that the Harris Poll reference.)
    I did a little further research and Googled “physician”, “guideline use” and “UK” to see how things were going on the “other side of the pond”. I found 4 articles about use of guidelines in other countries; 2 in Canada, 1 in England and 1 in Australia. Here is what these articles said:
    Canada – “Most (69%) respondents were unaware of the guidelines. Of those who were aware, 46% agreed with the guidelines and 39% claimed to follow the guidelines.”
    Australia – “Adherence to COPD-CPG recommendations was highly variable.”
    Canada – “Family physicians were minimally aware of the existence and the detailed contents of the CCCD guidelines.”
    UK – “Only 20% of physicians followed adherence protocols or formal guidelines.”
    Therefore it would appear that – contrary to what you said – U.S. doctors are MORE LIKELY to follow guidelines than physicians in other countries.
    Frankly, I am a little bit surprised by these results. I find guidelines quite useful and follow them whenever I can. I can think of one example that has not only cut done on the rate of follow up CTs, but made my life easier – that is the recommendations of the Fleischner Society for the follow up of small pulmonary nodules. In reading CT of the Chest it is very common to come across small indeterminate nodules that most likely are benign. Before the Fleischner Society came up with its guidelines, almost all of these “ditzels” were followed up with CTs – typically at 6 month intervals for several years – and that’s a lot of CTs. Now, I am able to NOT FOLLOW some of these with greater confidence that if something happens I can better defend myself – that’s right guidelines help me NOT to have to practice defensive medicine.

  26. re: guidelines
    Should US physicians be following COPD guidelines?
    http://www.ncbi.nlm.nih.gov/pubmed/17113277
    Well, maybe we should be following NCEPs cholesterol guidelines.
    http://www.theheart.org/article/215447.do
    Well, at least we should be following the ADAs diabetes guidelines on blood sugar control.
    http://hcrenewal.blogspot.com/2008/02/is-more-always-better-accord-study.html
    Let’s make sure we’re following all the guidelines for elderly patients with several common chronic diseases.
    http://jama.ama-assn.org/cgi/content/abstract/294/6/716
    And whose PSA, mammography ,and osteoporosis screeninig guidelines should we be following?
    And on and on…
    Guidelines, IF done right, can provide some guidance when deciding on medical care for a patient.
    However, they are often full of bias, both in the guideline recommendations and the studies used to inform the recommendations. They often reflect the myopic view of those in narrow clinical practice. They ignore the issue of prioritizing treatments in patients with more than one problem. They often ignore patient preferences and values.
    Guidelines should be just that, guides to care that may or may not be appropriate for the patient sitting in front of you. It has been said (and I agree) that a good doctor knows when NOT to follow the guidelines.

  27. pcb,
    Good point.
    I have already posted some of the DIFFERENT guidelines for screening mammography.

  28. pcb wrote:
    Guidelines should be just that, guides to care that may or may not be appropriate for the patient sitting in front of you. It has been said (and I agree) that a good doctor knows when NOT to follow the guidelines.
    —————–
    This is important to discuss more if we are ever to get a handle on what constitutes good and appropriate treatments for various patients. I know FFS incentives versus bundled payment incentives have been talked about as a way to try and incite appropriate treatments, but how will the “good doctor” wanting to do the right thing know what the good treatments are??
    If you put the providers with myopic views in narrow clinical practice together with your definition of the “good doctors”, and forced them to come up with the best guidelines for all providers together, what would the guideline then look like? Could some national coordination of guideline formation be put in place where a large selection of all types of providers were forced to form the best guidelines for all to follow?
    Surely your definition of the “good doctor” has some process and logic behind it that makes those the “good doctors”! What is that process and logic. Share it!

  29. NG,
    Medicine is an art, informed by science. Process and logic are part of the deal, the other part is experience, intuition, gut feel, human connection, relationships, trust, etc.
    If it were all about process and logic, then Dr. Google would be all you need.
    This is not to say guidelines are worthless. I think they are quite valuable if done right. But there is a lot more to good medicine than guidelines.

  30. pcb,
    Thanks for your reply, and you might be right about the art part of medicine. I sure would like to hear other’s point of view on this.
    I will say that the art part of medicine coupled with pooled resource fee for service payments surely explains the seemingly uncontrollable runaway cost of the system. You just cannot pay providers to use gut feeling to do whatever they want and pay them from pooled resources. I think you either define good treatment and limit pooled payments to those, or you just say the hell with it and let patients only pay for what they can afford personally from the arts menu!

  31. NG,
    You say: “I will say that the art part of medicine coupled with pooled resource fee for service payments surely explains the seemingly uncontrollable runaway cost of the system.”
    I don’t understand what you mean. Are you assuming that the “art of medicine” is more expensive than the “science” of medicine?

  32. NG,
    In my experience, personalizing care and practicing the art of medicine usually leads to ordering fewer tests and f meds. We have too much to do that often provides little real benefit for patients. When patients are given a true understanding of the evidence and how it applies (or doesn’t apply)to them, they’re more likely to decline further burdensome meds/tests/procedures.

  33. Legacy Flyer,
    What I mean is that if you don’t define something, you cannot ever control it! Sound familiar?

  34. NG,
    I am in agreement with pcb on this one. I think the “art of medicine” is cheaper than the “science of medicine”. Although both are hard to define, I would define the art of medicine as listening to and understanding the patient as well as other difficult to quantify skills such as intuition.
    I am reminded of an upper GI series I did many years ago on a kid of about 10. He had been sent to us by his primary care doctor to “R/O Ulcer”. As I was getting ready to start the study, I talked to the kid and asked him what made his stomach hurt. He replied “It hurts before I go to school”. I asked him if it hurt on weekends or other times when he wasn’t going to school. He replied “No, just before school”. As you might guess, the GI series was negative. This is a good example of how the cheaper “art of medicine” can give a better answer than the more expensive “science of medicine”

  35. Legacy Flyer, PcB, NG
    Legacy– Not sure where your numbers on docs in other countires following guidleines come from . ..
    Just Googling isn’t enough– as I am sure you know there is a huge amount of misinformation on Google. You have to look at the sources, the evidence behind the numbers. . .
    In the UK, NICE reports that 88% of physicians follow NICE guidelines; this sounds like a pretty good balance between paying attention to guidelines, and deviating when necessary. .
    Numerous studies published in medical journals as well as work by the IOM suggest US doctors are much less likely to follow guidelines than many others.
    Pcb– the comparative effectivness panel and oversight board that IOM and the administration have set up is purposefully designed to be made up of physicians and medical experts who have no financial interest in the outcomes.
    The people on the panel are not infallible but they are highly respected by their peers.
    Legacy–
    It’s pretty easy to see who has an axe to grind when issuing guidelines–and who doesn’t
    I’m impressed by the Breast Cancer Coalition because, unlike many patient advocacy groups, this Coalition seem to be thinking about the patient rather than simply trying to draws dollars and attention to “their disease.”
    Thus the Coalition warns that mammograms may do more harm than good—and that this is something individual women need to think about . .
    PCB and NG —
    Guidelines are always tied to patients who fit a particular profile; other guidelines for patinets for fit a different profile.
    We are not talking about one-size-fits all medicine.
    NG & PCB –Very interesting discussion on medicine as an art or a science–and which is more likely to save money.
    My own view– medicine begins with the fine art of listening to the patient–and talking– then moves to running a few tests to try to confirm the diagnosis based both on what one heard, a hand’s on examination of the patient. . . .
    But finally, when prescribing treatment, docs need to practice “evidence-based” medicine. Those who pride themselves on going on their gut, instincts, etc
    just haven’t kept up with all of the knowledge that we now have about what works and what doesn’t for patients who meet a particular profile. . .
    It’s not even a question of whether they waste money. Doctors who see themselves as “lone rangers”–going their own way– are, too often, egomaniacs, putting patients at risk.
    On TV they may look brilliant, but in real life, they’re scarey.
    This is one reason why we need to have doctors working together in groups-collaborating, and consulting with each other.

  36. Maggie,
    “the comparative effectivness panel and oversight board that IOM and the administration have set up is purposefully designed to be made up of physicians and medical experts who have no financial interest in the outcomes.
    The people on the panel are not infallible but they are highly respected by their peers.”
    ————————-
    And when I win the lottery, I’ll be rich. 🙂 When/if this panel actually exists, we can debate their recommendations.
    They will have biases, just different ones, as you acknowledge. And yes, some of those biases will be financial, likely in the opposite direction.
    For now, our guidelines are very messy, as I discussed in my previous post.
    ————————-
    “Guidelines are always tied to patients who fit a particular profile; other guidelines for patinets for fit a different profile.
    We are not talking about one-size-fits all medicine.”
    Guidelines are general guides. They do not, by definition, take unique details of individual patients into account. There is no guideline for “patient A”, there are guidelines for medical conditions patient A may have. Pateint A may have more than one medical condition, guidelines almost never address that fact. Patient A may have odd side effects if treated a certain way, and not want to follow the guideline. Patient A may have some important differences in his/her health that make the guideline questionably applicable. Patient A may have his/her own idea about certain recommendations (statins, HPV vaccines, etc) and decide to veer from the guideline. Patient A may have innumerable reasons why a specific guideline isn’t appropriate. Patient A’s physician can realize all of this, and use judgment, experience, intuition, and try to personalize care that uniquely reflects the overall needs of the patient. Or patient A’s physician can ignore all that and say “here’s what the guidelines say for all the things you have, you need to follow them.” I know what kind of doctor I want. If you rate doctors based on how well they follow guidelines, I know what kind of doctor you’re going to get.
    Did you read the link about what happens when we follow all the guidelines on an elderly patient with several common chronic diseases? That’s the direction we’re heading, and it is not good medicine.

  37. pcb wrote:
    I know what kind of doctor I want. If you rate doctors based on how well they follow guidelines, I know what kind of doctor you’re going to get.
    —————
    I guess this will boil down to how one sees the value and effectiveness of the current system where providers have been allowed to go it on their own with little tracking for system accountability purposes. If you think the “go it on your own” system, non-accountable, non-strategy with pooled resource payment has been a high value, high effectiveness success, then you are right. If you think the system is going bankrupt without the stats to show much value and effectiveness in many areas, then you want more uniformity that can lead to system accountability.
    Since the current system is unsustainable and ineffective for many, I guess we need change. If good care is not defined and measured, what changes will we really make?? Don’t get lost in esoteric anecdotes to thwart accountability potential, but treat the general majority of healthcare encounters in the system reform planning process.

  38. NG,
    “Don’t get lost in esoteric anecdotes to thwart accountability potential, but treat the general majority of healthcare encounters in the system reform planning process.”
    ————————
    Wow. I don’t even know how to respond to this.
    This is the future of medicine?
    Thanks for the interesting discussion.

  39. PCB–
    This works in other countries where doctors follow guidelines much of the time (not all of the time) deviating as circumstances warrant.
    Read the post I have written about NICE.
    Note that, outcomes are at least as good–and often better in these countries, that spend far less on health care and expect doctors to pay attention to medical evidence.
    You seem to indicate that, unlike other countries, the U.S. is incapable of assembling a panel of unbaised physicians and medical experts.
    In fact, a panel has alrready been appointed by the IOM. I know several people on the panel, and am impressed by the selections.
    Finally, the Mayo Clnic, Kaiser Permanente in Nirthern California, etc. All Use Guidelines. Their docs can deviate from guidelines but need to indicate, on the record, why they did so.
    Outcomes–and patient satisfaction- are much better at Mayo and “acccountable care organizations” where docs use guidelines.
    I auspect you need to read more about comparative effectiveness resarch, and how it is used at the best multi-specialty centers in the U.S., as well as abroad., and you will be more optimistic about what practicing medicine based on medical evidence will mean.

  40. “I auspect you need to read more about comparative effectiveness resarch, and how it is used at the best multi-specialty centers in the U.S., as well as abroad., and you will be more optimistic about what practicing medicine based on medical evidence will mean. ”
    Please.
    I suspect if you actually practiced medicine, you would have a more realistic understanding of the role of guidelines in delivering appropriate clinical care.
    As I said earlier, I appreciate guidelines and welcome good ones to help guide clinical decisions.
    I’m just a little more realistic about the limits (which I’ve listed several times)inherent in applying guidelines to individuals.
    And I’ve seen what guideline worship does to patient care.

  41. Maggie,
    You say:
    “Not sure where your numbers on docs in other countries following guidelines come from …”
    The info I quoted was from the first 3 journal article I came across. They were in “Canadian Family Physician” (2), “Internal Medicine Journal” (Australia) and “AIDS Care” (UK)
    You say:
    “Numerous studies published in medical journals as well as work by the IOM suggest US doctors are much less likely to follow guidelines than many others.”
    Please direct me to these studies – I did not find them in my search (which admittedly was not exhaustive).

  42. Legacy &pcb—
    Legacy– There are a zillion studies.
    See for instance “Medical Errors: Not Following Guidelines” on this site you will find failure to follow guidelines in treating everything from childhood asthma to heart attacks.
    http://74.125.93.132/search?q=cache:_jV9DXSNmeMJ:md-jd.info/abstract/not-following-guidelines.html+guidelines+and+IOM+and+deaths+and+aspirin&cd=17&hl=en&ct=clnk&gl=us
    There are also many IOM studies of failure to follow guidelines and importance of guidelines.
    One points out for instance that “18,000 deaths might be prevented each year in the U.S. if physicians more routinely prescribed thrombolytics, beta-blockers, and ACE inhibitors” for heart attack patients.”
    http://content.onlinejacc.org/cgi/content/full/38/6/1766
    pcb —
    On this blog we try to be civil. (“Please. I suspect if you actually practiced medicine . . .” Or “Ane when I win the lottery, I’ll be rich” isn’t really the tone we’re striving for.
    You’re quite right, I’m not an M.D. But I have listened to and talked to a great many MDs who I respect greatly–and you believe that guidelines are essential.
    No one is talking about “guideline worship.”
    That’s why they are called “guidelines” –not commandements, not rules.
    In the UK, as I may have mentioned, doctors now follow NICE guidelines about 88% of the time.
    Typically, these guidelines are as specific as possible, narrowing the group of patients who would benefit:
    For example, from NICE: “X is recommended as a possible treatment for locally advanced or metastatic non-small-cell lung cancer (NSCLC)
    if: the cancer is a particular type (adenocarcinoma or large-cell carcinoma)
    and the person has not had any treatment for NSCLC before
    The Economist has launched an online debate about guidelines and comparative effectiveness reserach.
    On one side (opposing the use of such resarach): Newt Gringrich.
    On the other side (supporting it) the head of NICE.
    The head of NICE is an M.D.
    Newt, of course, isn’t.

  43. Legacy &pcb—
    Legacy– There are a zillion studies.
    See for instance “Medical Errors: Not Following Guidelines” on this site you will find failure to follow guidelines in treating everything from childhood asthma to heart attacks.
    http://74.125.93.132/search?q=cache:_jV9DXSNmeMJ:md-jd.info/abstract/not-following-guidelines.html+guidelines+and+IOM+and+deaths+and+aspirin&cd=17&hl=en&ct=clnk&gl=us
    There are also many IOM studies of failure to follow guidelines and importance of guidelines.
    One points out for instance that “18,000 deaths might be prevented each year in the U.S. if physicians more routinely prescribed thrombolytics, beta-blockers, and ACE inhibitors” for heart attack patients.”
    http://content.onlinejacc.org/cgi/content/full/38/6/1766
    pcb —
    On this blog we try to be civil. (“Please. I suspect if you actually practiced medicine . . .” Or “Ane when I win the lottery, I’ll be rich” isn’t really the tone we’re striving for.
    You’re quite right, I’m not an M.D. But I have listened to and talked to a great many MDs who I respect greatly–and you believe that guidelines are essential.
    No one is talking about “guideline worship.”
    That’s why they are called “guidelines” –not commandements, not rules.
    In the UK, as I may have mentioned, doctors now follow NICE guidelines about 88% of the time.
    Typically, these guidelines are as specific as possible, narrowing the group of patients who would benefit:
    For example, from NICE: “X is recommended as a possible treatment for locally advanced or metastatic non-small-cell lung cancer (NSCLC)
    if: the cancer is a particular type (adenocarcinoma or large-cell carcinoma)
    and the person has not had any treatment for NSCLC before
    The Economist has launched an online debate about guidelines and comparative effectiveness reserach.
    On one side (opposing the use of such resarach): Newt Gringrich.
    On the other side (supporting it) the head of NICE.
    The head of NICE is an M.D.
    Newt, of course, isn’t.

  44. maggie,
    Telling someone who’s trying to point out some of the serious limitations of guidelines (even listing impotant examples that you ignored) that they “need to read more studies on comparative effectiveness research” so their opinion becomes the correct one (i.e. yours) set the tone for my response.
    I understand the role of guidelines, I think they are important, and you articulate that opinion well yourself. I also, however, understand their limitations, and much of that understanding comes from experience. I also understand that the devil is in the details re: guidelines, and statements like “guidelines are good” aren’t very helpful. (which is why I listed several specific guidelines and their problems).
    I do not understand why you have such trouble with people pointing out some of the concerns regarding guidelines in medicine.

  45. pcb–
    I have no problem with people pointing out that
    guidelines have limitations.
    But I take that as a given.
    That is why, every time I write about guidelines I always say “guidelines, not rules,”) and point out that doctors will need to deviate from guidelines to respond to the needs of particular patients.
    Meanwhile, at this point in time–when opponents of healthcare reform are suggesting that use of comparative effectiveness info to set guidelines constitutes a “govt’ takeover” of health care, I’m not sure why someone like you–who agrees that by and large, guidelines are a good idea–would be
    so adamant that, inevitably, the people who set guidelines will be biased, and guidelines will be “worshipped.” ???
    In medical centers within the U.S. (Kaiser, Mayo, the VA and in other countries (the UK,etc.) many doctors have found guidelines useful–and in each of these cases, doctors can deviate from guidelines as they see fit.

  46. maggie,
    “In medical centers within the U.S. (Kaiser, Mayo, the VA and in other countries (the UK,etc.) many doctors have found guidelines useful–and in each of these cases, doctors can deviate from guidelines as they see fit.”
    There is a movement afoot with a lot of momentum to rate or grade or group physicians and physician groups based on the “quality of care” they deliver. This “quality” is largely (almost exclusively) defined by what percentage of patients are meeting guidelines. (at least at the primary care level)
    Doctors who carefully individualize care, understanding the limits of guidelines, using them cautiously and appropriately, will almost certainly have lower rates of “guideline adherence” than those who apply them less judiciously.
    Thus, guidelines, will become the definition of good care, and doctors who follow them blindly will be measured as giving better care.
    You can say that doctors can deviate as they see fit, but if there is a looming penalty from their accountable care organization leadership for their “lower quality care”, most will soon toe the line.
    I do not see this as a positive development.

  47. Maggie,
    Don’t think you got my point. I don’t dispute that physicians in the US don’t follow guidelines with a very high frequency. My research suggests that NEITHER DO FOREIGN PHYSICIANS!
    Hence your statement:
    “The U.S. is the only country where doctors routinely ignore guidelines for best practice.”
    Is not true – not true in the sense that the U.S. is the ONLY COUNTRY.
    The studies that you have pointed to do not compare rates of compliance with guidelines in the U.S. versus other countries. Again, I will ask for your references.