Tuesday, June 22, 2010

Finally, A Patients' Bill of Rights?

Today Obama announced what he's calling a patients' bill of rights. I've yet to see the "bill" but suspect that it regulates insurers' practices. From everything I'm reading, the details are still shaking out, but I doubt that it will become the bill of rights I've been advocating for: one that guarantees non-discriminatory health care delivery to all citizens regardless of age, race, sex, gender, faith or ability. I doubt it will include strong informed consent laws and mandatory referral laws that prevent providers from refusing services to patients. Perhaps the administration is waiting to tackle the "conscience clauses," most notably Bush's law instituted in December before he left office, and currently on pause since the election.

More news:


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The AMA's "Free-Market" Legacy.

Well here's a fascinating little tidbit from June 9 that I'm slow to come across, below. A new study shows that a majority of AMA members opposed the association's position on health care reform. Now, why would doctors support the expansion of Medicare to cover uninsured patients and not a professional association like the AMA? Why would the AMA prefer "private means" of expanding coverage to the uninsured? It's an easy question to answer when you look at the traditionally conservative, paternalistic nature of the organization and the field. I know that I'm over-generalizing here but the study proves my point that the AMA is grossly more "free-enterprise," and conservative than it's members. (Kind of recalls to mind the nature of the debate between the USCCB and it's unabiding "adherents," the CHA, women religious, and lay members.)

This report makes me pull out an article that the former chair of the AMA's Ethical and Judicial Affairs sent to me when I asked him about health care as a human right. It was published by the Cato Institute in 1998, and alleges that, "The right to health care is perhaps the most widely accepted of all welfare rights." Indulge me while I include the important following paragraph:

In the end, however, that argument is flawed in the same way as any other appeal to the notion of positive liberty. Obtaining treatment for illness or injury is obviously a human need, but hardly a more important need than obtaining food or shelter. As with all other goals, people need the freedom to weight it against other goals and to choose the means of obtaining it. But they cannot define their freedom in defiance of the facts, or at the expense of the freedom of others. Illness and injury are natural risks inherent in life, and all the means of dealing with them -- from aspirin, to open-heart surgery, to health maintenance organizations -- must be produced by human effort to which no one can have a right without the producers' consent.

The producers here, of course, are doctors and the medical industry. How dare sick people expect others to meet their care needs? Let them sink or swim in the free market where medicine should be a commodity and "natural risks inherent in life" should be carried for the sake of liberty.

The report:

Researchers at Mount Sinai School of Medicine have found that the majority of physicians and members of the American Medical Association (AMA) opposed the AMA's position on coverage expansions--the most contentious issue in the recent health care reform debate. The data are published in a letter in the June 9th issue of the New England Journal of Medicine.

In the 2009 debate, the AMA opposed Medicareexpansions and proposed coverage of the uninsured primarily through private means. The researchers found that only 12.5 percent of all physicians and 14.2 percent of AMA members who participated in the survey supported the AMA's position on insurance coverage expansions. Salomeh Keyhani, MD, MPH, Assistant Professor of Health Policy, and Alex Federman, MD, MPH, Assistant Professor, Medicine, Mount Sinai School of Medicine, co-authored the study.

"Our survey indicates that most physicians and AMA members oppose the AMA's views on coverage expansions," said Dr. Keyhani. "The AMA is a highly visible organization that is presumed by many to represent physicians' opinions on various issues. However, there appears to be a discrepancy between the AMA's platform, the beliefs of its members and the views of physicians nationwide."

Mount Sinai researchers used the AMA Physician Masterfile to survey 5,157 physicians. The researchers secured a 43.2 percent response rate. There were no significant differences in response based on specialty, practice type, or geography. Physicians that were most supportive of the AMA's position were doctors of osteopathy (16.5 percent), physicians whose income was based on billing (16.1 percent), and physicians in rural areas (16 percent). The lowest level of support came from female physicians, with only 7.9 percent supporting the AMA's platform. Physicians who back the AMA's position were more likely to be younger, male practice owners in nonmedical or nonsurgical specialties such as anesthesiology, pathology, or radiology, fields that typically involve less patient interaction.

Respondents to the survey were asked to indicate their support on key issues, including the public option, expansion of health insurance through private means, and support for a proposal that would allow adults 55- to 64-years-old to buy into Medicare. were considered to be in support of the AMA's position if they agreed with private expansions only and opposed the expansion of Medicare.

Provided by The Mount Sinai Hospital

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Reigning In The Cost of Futile Care.

Stella Fitzgibbons writes at the LA Times that the costs of futile care are going to be difficult to reign in. And I post the entire article below because the LA Times site is so full of medical insurance, AARP, and drug ads that it's hard to see the story for the promo. (Of course, this comes from fantastic Thaddeus Pope over at Medical Futility Blog.)

As a hospital-based doctor, I am one of the people responsible for the country's ever-escalating cost of healthcare. And I can tell you that the new healthcare plan will do nothing to restrain me.

There is enormous pressure on healthcare providers to continue practicing the most expensive medicine in the world. To resist that pressure, we need some help from policymakers.

Consider the case of a man I'll call Mr. A. At the age of 80, he is admitted to intensive care after a huge stroke. He also has pneumonia and kidney failure. He is too sick to tell us his views on aggressive care at the end of life, but his family is happy to fill the void. They insist we use every tool at our disposal to prolong his life, despite brain scans making it clear that he will never again be able to walk, talk or feed himself. The total bill for the last month of life? Many tens of thousands of dollars.

Or contemplate Mrs. B's case. She arrives at the ER with shortness of breath. Tests find iron deficiency anemia. The most likely cause, based on her history, is an ulcer — probably a benign one. We can perform an upper GI X-ray, do a blood test for a bacterial infection that commonly causes ulcers and send her home with pills. Or we can opt for more precise, and far more expensive, tests in which a specialist examines her innards with a fiber-optic scope and takes tissue samples. In rare cases, this procedure catches something an X-ray can't. When presented with the options, the patient chooses the scope. The result? She spends an unnecessary night in the hospital, has $1,000 or more of tests and goes home with the same diagnosis and the same medicines she would have if we'd done the far less expensive X-ray.

And that's not all. Once patients like Mrs. B are diagnosed, they often insist on being prescribed the ulcer medicine they saw last week on a TV ad, which is likely to be a new (and expensive) medication rather than one of the reliable drugs that are older and cheaper.

Both of these patients are composites of people we see at the hospital every day, and they demonstrate why it will be so hard to rein in healthcare spending. Americans have spent the last several decades hearing that all you have to do is be a little assertive to get top-of-the-line treatment. They have had prescription coverage through their health insurance for so long that they have trouble understanding why I won't prescribe a convenient Z-Pack of antibiotics (at a cost of $60 or so) instead of amoxicillin, which they have to remember to take three times a day (at a cost of about $4). Websites and magazines tell them that if the doctors say a condition is untreatable, they should shop around for a specialist, or bully the doctor into trying an experimental treatment and the insurance company into paying for it.

Healthcare rationing is already in place, of course, for uninsured people. If they qualify for care in public systems like the one in Houston's Harris County, where I live, it takes weeks to get through the administrative process and longer still to get an appointment at a clinic. And if a patient needs a specialist, that will mean another wait, which can lead to life-threatening delays in diagnosis and treatment. Medicaid (and soon Medicare) patients also face rationing of a sort, in that they often can't find doctors willing to treat them.

Paradoxically, even as costs are rising, hospitals and doctors are finding their work to be less and less profitable. Even the best insurance plan won't cover the entire cost of Mr. A's hospital stay these days, and Mrs. B's HMO may deny coverage for even a one-night hospital stay. Doctors who accept patients admitted from the ER are often working for free or paid a small subsidy by the hospital, and those who see uninsured or Medicaid patients in their offices are unlikely to recoup enough to cover their overhead for the visits.

Some efforts are being made to control costs. Hospitals keep an eye on "unnecessary days," and medical personnel are becoming experts on "cost-effective care." But the savings of such efforts are insignificant compared with what we spend on futile care at the end of life, or expensive tests and treatments that lead to better outcomes in only a tiny fraction of cases.

Even though President Obama's healthcare plan will expand the number of people with insurance, it won't change the reality that we cannot afford to give every patient and family all they want, or to provide four-star medicine when the three-star version is almost as likely to succeed. Decreasing payments for services will only force hospitals to close and doctors to stop accepting new patients.

Unless someone comes up with a rational program for deciding healthcare priorities, American healthcare is going to become too expensive for any but the rich — and for members of Congress. Don't we deserve better than that?

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