Cornyn the Barbarian! Thanks for gracing Sermo with your presence. Can your survey be any more biased and leading in its questioning?!? All you need now is a link to donate money to the GOP after instilling the fear of government takeover into the trembling right wing docs on Sermo.
Senator Cornyn, Thank you for asking for input from the Sermo community. Howard Dean is correct. Walk into any medical practice and speak with physicians about defensive medicine and you will see very rapidly that this is a huge problem in American medicine and results in a tremendous amount of waste as well as interference in a trusting physician-patient relationship.
The idea of comparative effectiveness research is so ridiculous that it is almost laughable. To think that some panel in Washington will help physicians avoid litigation by publishing a laundry list of best practice recommendations is just folly.
There are very few things that we do in medicine that we all agree upon. And to add to that, medical care is a dynamic, fluid situation which is constantly changing.
We all look to consensus guidelines in our practices daily to help with critical decision making. Most of these consensus statements are the result of years of arduous work on the part of researchers and clinical investigators. These things just don't appear because congress wants them.
For example, we have guidelines for the management of gastro-esophageal reflux and for the management of thyroid nodules. I use these guidelines daily, but they took years to develop and are still changing.
This comparative effectiveness push is just a cover to avoid true reform of our malpractice system. I'm sure that you know this. Now, let's do something real about it!
1. deeply involved - JOHN, WHERE HAVE YOU BEEN in ALL of these years!
2. bring down the costs of health care... How much is your CO-PAY at your last visit!
3. increasing access for millions of Americans - 12milllion (but they have health care access)... .. WHY do you need their votes???
4.. medical liability reform and the practice of defensive medicine - More... XANAX to go to sleep!
5.. "people who wrote [the bill] did not want to take on the trial lawyers" - They (Washington/Congress) RESIDE in DC dont need the trial lawyers... they are in BED with them!!!
6.. Former DNC Chairman Howard Dean - He is an AUTISTIC former PEDIATRICIAN stilll fuming!
7. . "increase the federal government's role in comparative effectiveness research to determine which treatments"... BOARD CERTIFIED politicians who need to SUPERVISE idiotic docs like me!
8.. "value the perspective of practicing physicians"... WHAT!!! , hmmmm never heard before!
9. "evidence-based medicine"... STILL DRUNK in the middle of the ROAD clinging for dear life!
10.. "opinions and insight are critically important " ... SOS for another DC bailout because docs are LEAVING and looking for another job!
"one-size-fits-all" - LEAVE the DOCTORS ALONE.... they know what to do, thats why they became doctors in the first place!!!! NOT CHIROQUACTORS!...
PS .. SERMO docs voices earlier... were thrown into the WH GARBAGEand still fuming GARBAGE medicine!!!!!
Thank you for your interest in this aspect of the healthcare discussions. I agree that malpractice reform is essential, and you state that it has been a success in Texas--can you show us the numbers, though? Others have stated that the tort reforms done in TX and CA are evidence that reform doesn't save much at all. I'd welcome data, if you have it.
Senator, thank you for your willingness to ask for our opinions. I agree 100% with Ramstrong that the concept of comparativeness research is a very bad idea and just another way to ration health care.
In Cardiology, we have taken the lead in having well developed and tested guidelines and appropriateness criteria for most of what we do in Cardiology. We have guidelines for heart attack care, heart failure, angina, pacemakers, echocardiography, stress testing, heart catheterization, bypass surgery and many others.
With utilization of these guidelines and appropriateness criteria, we have seen a decrease in morbidity and mortality from cardiac diseases over the past decade of 27%. Instead of using our proven criteria, the government has ignored the ACC and ignored our data and has decided that it needs to do its own comparative research. What that tells me is that the government does not want to do what saves patients lives, but what will cost less money.
It is time that your colleagues in Washington start doing what they have been elected to do, take care of their constituents!
I agree that tort reform has helped in Texas. As a Texas pediatrician I have seen my malpractice premium drop every year since tort reform started. Our practice even got a dividend that paid for one full month's malpractice insurance. Starting with tort reform is a must.
Having politicians who have no clue about medicine write a list of how to practice medicine with each diagnosis is absolutely ridiculous. I am in pediatrics in a major medical center where there is a lot of antibiotic resistance. What is required to treat my patients is far different than what is required for patients in rurual America. One size does not fit all.
I do believe that comparative effectiveness research is a good expenditure. It is certainly better than relying on the pharmaceutical companies to twist our arm into rxing their meds based on only their data; this is the only info we get these days. Not sure how it would directly impair my ability to take care of patients as I see fit in the long haul.
Yes, tort reform in TX has really helped me as a general internist in TX and should be applied nationwide.
I am in TX, also inactive licensed attorney as well. Tort reform here capped non-economic damages at $250,000. That is where trial lawyers jack up damages for such economically speculative things as "pain and suffering." I have been there on both sides so I can speak to this issue. TX has had a marked decrease in liability premiums and a net influx of physicians, so much so that medical licensure in TX has long time delays due to the increased number of license applications.
I agree with Sermo Doc 2. I agree with the attempts made by Senator Burr and Coburn in the senate with the patients choice act and similar legislation HR 3400 in the house. It is sad to see that the media has give no serious coverage to legislation that would lead to true reform.
My understanding of the Maine medicaid system,is that if you follow approved quidelines ,this can be used as an affirmative defense ,if sued. Although tort reform would be preferred,at least this could be an idea to consider.
Wow we have a dermatologist telling us that tort reform would not decrease costs. Funny but I don't think he or she deals in the same type patient care as we do in primary care. also texas and cal are not examples of tort reform they are examples of capping rewards. tort reform would need to be based on only cases of true malpractice going to court. this may never be totally feasable but a panel of experts reviewing cases before they are able to go to litigation would help. It would take years before we would change our protective habits but in time the wasteful testing would slowly abate
Comparative Effectiveness Research (CER) is going to happen. It is, as you noted, important to use this appropriately. Given that government is the largest payer of health care in the country, it is also appropriate, I believe, for government to play a part in paying for this research.
Where I would like to see it go would be to utilize a model similar to the NIH, where CER is spread out through grants to many investigators and institutions, all with their own points of view. It is nonsenical to believe that a single monolithic institution can come up with every good idea for research and do it well, no matter how smart the people in the institution are. For scientific research, while the NIH campus produces some excellent research, many excellent studies are being done using NIH funds elsewhere in the country. While everyone has issues with who gets funded and for what, in general, this is a system that works to encourage innovation and new ideas from everyone. As noted above, created good guidelines takes time and effort, and in the current research funding schema is rarely rewarded since it is not discovery oriented work.
Better data is needed to determine guidelines. The important thing is to make sure that guidelines are flexible enough to take care of patients that don't meet the standard or make sure that failing to follow the guidelines do not constitute malpractice as is commonly thought amongst the non-medical public.
John,
Thanks for taking an interest.
Would the members of Congress, their staffs, all employees of the Executive and Judiciary Branches be willing to accept a limitation on their care as a result of their physicians using comparative effectiveness? From where is the data for comparative effectiveness derived? What about research from one institution that does not agree with research from another? I treat a lot of sinus infections (confirmed by history, physical examination, and plain x-rays or CT. There is no accepted definition for ""sinusitis," especially "chronic sinusitis." If a study from England shows that ten days of amoxicillin does not result in resolution of "sinusitis" when the use of radiography is not used in making the diagnosis, and a long term study from a US institution shows that longer term use of antibiotics with less bacterial resistance, with confirmation of an infection by CT scan, shows that resolution of a sinus infection can be achieved, whose data do you use to develop government guidelines? How does a panel made up of lawyers, union members, and teachers develop such guidelines?
And yes, tort reform in Texas has been effective in lowering my liability insurance premiums. Without tort reform, this year's premium could have be double what it was.
Defensive medicine: If someone comes to me complaining of a headache that just won't go away and says, "I am afraid I have a brain tumor," you can bet the farm that I am going to order an MRI and refer the patient to a neurologist.
The Federal Government now funds most of the basic and clinical research anyway, so the CER would be one more area that needs to be researched according to the well defined priorities by the non governmental IOM.
The results of that research will certainly help answer some important questions and guide ( not dictate) most appropriate practices, after all, most of our advances in medicine resulted as a consequence of research that is evidence based and was trnasmited to us during our training and through our careers as we keep up with the knowledge, unbiased research funded by unbiased agents is essential to come to appropriate conclusions.
As far as tort reform I believe every one should emulate the Texas example and is esential for an accrued savings of close to 200 billion a year, this money really do not contribute to the improvement of health care or medicine. I have been appauled to see the lack of efforts to tackle the issue in innovative ways that can both help patients and the health care system, such as the creation of no fault systems, medical forums, limitation to the plaintiff's profits and many other specific approaches about the legitimacy of an individual litigation.
I am also concerned about the fact that many areas that need to be considered, immediately if we are to be successful in implementing a health care reform have been neglected and certainly if we continue our system for the delivery of care and not develop a new and more appropriate systems of care every calculation of any budget office will miss the mark and we will end up with an even bigger deficit. The change should take place starting with the curriculum at the medical school, the trainingduring residency and the appropriate reimbursement systems based on a different approach to the care of the patients wher the weight is placed on outcomes.
As a Texas OB-GYN tort reform has been great for Texas and Texas citizens. Doctors are flocking to Texas and why not. Great place to live, great economy (better than almost anywhere else), great income tax (none), GREAT PEOPLE!. Tort reform here will of course be destroyed by Obama. Things will go back to the way they were. I quit OB because of tort and will quit medicine with Obama care. The government managing medicine. What a joke. Those that want governement medicine please work on an Indian reservation for 3 months and then come back proclaiming how great it is.
Greetings. As I understand it there are 2 driving issues behind health care reform:
1. Expansion of coverage for health insurance to the uninsured.
2. Reduction in the cost of heatlh care.
Properly conducted, comparative effectiveness trials could provide useful information to physicians. Presently FDA requires demonstration of efficacy and evaluation of toxicity of candidate drugs compared to placebo. Once a drug is approved by FDA, pharma has a disincentive to refine patient selection and to conduct comparison trials with alternative treatments already on the market. There are some notable exceptions to this but that is the usual scenario.
The problem is that no one who thinks seriously about health care reform believes that comparative effectiveness trials will accomplish either of these goals. First of all, it will take many years to definitely arrive at optimal treatment informed by well designed trials. When there is a clear winner, why would it cost less? If anything, the drug will be less of a commodity and more of a must-have. The price could possibly rise instead of fall. One could argue that by using optimal treatments there would be avoidance of complications and we'd have better outcomes. This may be true in some cases but the idea that this will significantly impact the cost of health care is wishful thinking. The bottom line is that well designed research including comparative effectiveness trials is a good idea but to tie that into the health care reform package and present it as a plan to accomplish the two broad goals is inappropriate.
Sermo Doc 13, excellent points. I could completely support increasing the amount of money available from the government for research as long as it went to facilities nationwide with the goal of accumulating large data bases that are evaluated by a large cross section of astute investigators. This is the kind of CER that results in guidelines that are widely utilized and accepted by physicians as worthwhile.
Also, as you said so well, guidelines are just that. Patients are not homogeneous beings that fit into the boxes of algorithms. Well trained physicians understand the guidelines and use them to assist in delivering excellent care. They should not be thought of as a defensive move, rather they should be perceived as good medical care.
Dear Sir,
Stay out of healthcare completely.
End all entitlement programs,
end employer provided insurance,
end anti trust protection for insurance companies,
allow physicians to negotiate fees collectively from insurance companies,
place endless beaurocratic redtape upon legal profession with CPT type system for legal services,
allow purchase of insurance nationwide as is car, homeowners, etc.,
allow catastophic health insurance only,
make insured have some skin in the game,
serious malpractice reform,
COngress MUST have whatever they create apply to them and families 100%, no special insurance and medical access for legislators,
I could go on and on.
PS stop talking to the AMA as they do not represent the majority of practicing physicians, end the CPT codes immediately
I find it interesting that only now are some folks demanding that Congress itself must have whatever coverage results from health care reform. The implication is that the results of this legislation will be worse than what we have in place right now.
Well, I'd like to know where have all these same folks been for all these years that Sen. Cornyn and other Senators and Congressmen have had the premier, best, Rolls Royce health care coverage that money can buy? Why were they not demanding that Congress either give us all the same deal or step down to our level out here in the real world? Why is this demand now being placed on Congress? Is it only to give more ammo to the idea that reform is bad and is another last ditch effort to demonize the public option which we all know is desperately needed?
Welcome, Senator Cornyn. I believe the population's medical needs are increasing because people are getting fatter and sicker. Washington is focusing too much on how to reduce the cost of meeting the population's legitimate medical needs and not enough on how to prevent them from getting fat and sick in the first place. I think reforming the food industry would do much more for the health of our population than would reforming the healthcare system. If people continue to eat unhealthy diets, our population will continue to get fatter and sicker, costs will rise, whoever pays for care (the government or insurance companies) will ration more and more (even if they don't call it "rationing"), and nothing will get any better.
Sermo Doc 20, please do not count me among the physicians that ALL KNOW the "public option" is desperately needed. WE desperately need to deal with the root problems...true tort reform is among them. The "public option" just adds another layer of government bureaucracy and regulation. It wouldn't fix anything and would drive up costs as well as taxes.
Senator Cornyn Any "one size fits all" question deserves no answer. Comprehensive health reform will not lead to "one size fits all." That is a misleading and inaccurate characterization. If you're interested in "one size fits all" you would do better to look at the insurance companies and their proclivity to deny all kinds of needed care and prescribe what they will or will not pay for. They even deny patients (i.e. "prior existing condition") any care at all. As far as tort reform, that's a complex question. Law suits do, unfortunately, lead to defensive medicine which is expensive. Capping awards saves the insurance companies money and they give some of it back to the doctors (not all of it by a long shot) in the form of reduced premiums. However, we know that there are a vast number of medical mistakes taking place each year, causing vast amounts of injury and death. I hate to see people grievously injured denied what is coming to them and what they need. I would be in favor of a plan practiced in either Australia or New Zealand whereby doctors make an annual payment into a fund. When a patient is injured by medical mistakes, application is made to the fund and a reasonable amount is paid. This works out a lot cheaper than our current system but it doesn't deny hurt patients their due. Senator Cornyn, I know what you are against in health care reform. I have yet to see a comprehensive health care reform proposal from your corner, i.e. what you are for. It doesn't exist. I tend to agree with Rep. Grayson of Florida. His take on the Republican position is that Republicans basically favor telling patients "don't get sick" and, if they do, "die quickly." That may be crass but it's a pretty accurate rendition of Republican health care reform.
Agree with Sermo Doc 2, and let me practice medicine. No more goverment bureaucracy, no more third party intervention in my medical care, no electronic medical records, no unfunded mandates. Patients should pay me for my medical services at my office, not through medical billing companies ( service that is an unfunded mandate, that comes out of my pocket ), or inhouse medical billing. Balance bill should be my constitutional right.
Additional information: Since tort reform in Texas, my medical liability insurance premium had decreased 23% for the same coverage.
If Congress does not include themselves, the Executive, and the Judiciary in any medical care program that passes (it must be mandatory, and not choice for the government employees and elected and appointed officials) it smacks of ELITISM, and, John, we fought the Revolutionary War to tell King George that there are no elitists in our government. All elected and appointed officials MUST, upon reaching age 65, be enrolled in Medicare as their primary health insurance, whether any "reform" bill currently being considered passes or not. An 85 year-old Senator should not be allowed to have knee-replacement surgery if no other 85 year-old citizens are allowed to have the same procedure.
And Sermo Doc 24, the Republicans have several proposals in Congress for health care reform that encompass much of what has been written here.
Will you be joining the demonstration of American people and Doctors at the Capitol tomorrow, Thursday Noon, organized by Rep. M. Bachmann (R), MN, and will you be available for questions afterwards when people circulate through the Capitol and Office Bldgs. to speak to their Congressmen about their Health Care concerns?
"old"doc2-- indeed. Since you must be retired or near so, please exclude yourself from the debate that affects those of us that have to endure this legislative idiocy for another twenty years. After practicing in the heyday of unchallenged reimbursements and minimal documentation requirements, anyone over 60 should have no say in the transformation of medicine today.
Ramstrong for President! (or any other elected official unwilling to kowtow to special interests and fight the deluge of lobbyist dollars stroking Congress and other bureaucratic dullards). You express my sentiments eloquently and succinctly—minus the interjection of profanity. :-)
Sermo Doc 2,
Can you organize anyone to meet with Rep. M. Bachmann, (R), MN, at the Capitol demonstration tomorrow, Thursday, high Noon, followed by visits to Congressional offices for talks with cell phone cameras in hand??
I am aware of Michele Bachman's call to make house calls in the congressional office buildings tomorrow at noon starting at the capitol. This was a last minute call to action on her part...delivered on Sean Hannity's show last Friday. I don't personally know of any physicians that are going. But, I would encourage all physicians to go to Washington, make an appointment with your Representative or Senators or both and meet with them. Tell them directly how you feel and what your problems are in your practices. When you go, be very well informed, do not ramble or spout platitudes. If you meet with their health aides, you will quickly realize that they are on top of this stuff. It is their job to do it full time and BS won't work with them.
Be truthful, be sincere and make your case with facts. Honesty and truth are VERY powerful and are very difficult to ignore. Your congressman/woman will be impressed that you took the time to show up. It is helpful.
The nation needs tort reform, not a legislation that will penalize states that have enacted same (as would the Pelosi bill). Alternately we need to be assurred our constitutional right to trial by a jury of our peers - those with MD or DO degrees who are practicing medicine, not by lay persons with no concept of biology or medicine.
I do not follow paradigms prescribed by academicians (and I used to be one). Metformin is now considered the first line and most important med for type 2 diabetes, finally, 15 years after it came to the US. I was using it that way already in January 1995, the month after it hit the market here, against all the then current paradigms. Do we want our care to be 10 years out of date? Then let's follow government paradigms that do not allow us to think or individualize.
If you want to lower costs and improve care, get the government and the managed care industry out of the doctor's office.
Assuming you are taking the comments on this string seriously (or at least taking the serious comments seriously) the following points manifest themselves
1) Physicians are actually quite divided about health care reform, the best way to go about it, and what the cost savings would be. I personally agree with the need for a robust public option as a means of covering the uninsured in this country - we need to do something to stop the 40,000 unnecessary American deaths that occur due to lack of coverage. Perhaps we can at least agree on the morality of this. Unfortunately I sometimes percieve this as less of a priority among some of my fellow healers than preserving the status quo, which lets face it, is fundamentally irrational, loaded with perverse incentives, and does not provide value fo the money; value on the dollar by the way as being one of the 'conservative' principles I completely agree with
2) As the government already picks up the tab for roughly half the health care costs, to have NO comparitive effectiveness research is, again, wholly irrational. I guess I would argue this not only as my fiscally conservative nature dictates (#1), but also as a taxpayer who does not like paying for the healthcare equivalent of $500.00 hammers. Further I sort of agree with Sermo Doc 13 about the need for different institutions to participate, but know as a researcher that multi-institutional studies are often the best way to answer pressing questions. And I can tell you, as I teach health care policy at my university (among many other things) that the questions are many.
3) It is obvious that almost all physicians, right and left, agree on the need for tort reform. The current system, no matter what figures one uses is, again, completely irrational, rewarding tort attorneys disproportionately over the injured, and doing nothing to enhance quality health care
4) the American College of Surgeons has endorsed HR 3961, in part because it repeals the Sustainable Growth Rate. As I recall, you were one of the senators who voted AGAINST that repeal. Unless that goes, you will get no serious buy-in by physicians.
5) The preceding comments are written, as I have said before, under the assumption, sir, that we can take your word at face value and think you are seriously obtaining our input, rather than merely trying to score political points. If the latter is the case, than I, as a practicing surgeon, have real patients to take care of, and my time is at a premium
Sermo Doc 26, I appreciate your comment. It is powerful motivation for me to continue what I believe is so very necessary in this debate. All organizations of humans will have differing points of view. We see philosophic discussions here and in all of our endeavors that run the gamut from extreme left to extreme right. In my experience, most of us can support neither, but fall somewhere in the middle, in the center, where common sense ideas reign. There is nothing more important in all of these discussions than trying to get to the heart of what truly matters, not only for physicians, but for patients, which we all are or will become.
As we move forward in this process, I believe that we have to go beyond political rhetoric, we have to go beyond posturing and bullying and get to the root of the honest problems that plague not only our profession, but also our nation.
I believe that this is a great country. Having done some traveling internationally, there is no other place that I would rather live. I believe that we still have a functional democracy and that we still have media that cover the issues from several perspectives. I also believe that the nation, as a whole, has the ability to balance itself toward the center, where common sense lives, in issues large and small.
I talk quite a bit with my father-in-law. He is a retired pipe-fitter, dropped out of school in the 8th grade to go to work. He is 82, has worked hard all of his life and still prides himself on a job well done. If I need to fell a tree, I ask for his help. He knows just where to cut and can put it down exactly where he says it will go. He is not educated in a formal sense, but he is one of the smartest men that I know. He listens to these debates and he can point out the BS just as accurately as he can fell a tree.
There are a lot of people in America like my father-in-law. They know when things don't add up and they know when the politicians are trying to sell dreams. I think our nation owes these people honesty and hard work. I'll keep going.
I have a lot less interest in the senator after he voted to stiff us in favor of medicare advantage. He did change his vote to us later after the outcry. I can't help but believe he is in the pocket of the big insurance companies. Sorry, senator. I might add I am lifetime conservative republican who can't see how giving the extra money to the insurance companies is anything but a waste of tax dollars. I also agree the democrats are worse.
Sen cornyn..Just in case you really want to know what is happening to brilliant, educated people like real doctors who sweat and toil for the poor and needy..here is the link.
I had not read Wonposet's post until today. Most of us in primary care are struggling with such low payments from third parties. Senator, please take note at Wonposet's post. It represents most of the primary care physician's plight. I don't see primary care physician pracitces surviving with the 21.2 % cut from Medicare.
I come from a family of docs, 2 uncles and 10 2nd degree cousions, as well as my brother and 1st cousins.None of our want to carry on the tradition . furthermore, we haven't encourage nor coerced them to do so!they see want we've all gone through and they don't want any part of it. sadly, I don't know who Obama and congress think is going to carry the torch!
I have come from a family of doctors: my 3 uncles, and 7cousins and my brother. not one of our kids wants to be a doctor nor would we try to coerce them to be. the smartest, most dedicated now aren't going to be doctors in upcoming generations.
Senator, thank you for continuing to show interest in moving this country toward REAL reform in health care - rather than the special-interest giveaway that is being packaged behind closed doors in Washington.
Tort reform IS critical - and it is ludicrous that the Dems have avoided it so completely in order to curry favor with such a small group of Americans (who happen to give over-sized campaign contributions.)
The Senate SGR shenanigans WERE political games and the vast majority of physicians recognized it. The Senate 'repeal' would have caused far more problems than it solved. SGR still needs to be addressed, but I agree with the defeat of the previous maneuver.
CE research COULD be very helpful. BUT.... I have serious doubts that a cash-strapped government insurance plan would seriously invest in ***good*** science to get the BEST answers. I DO believe that the government would pursue CER via entities so beholden to their gov't funding that they would bias results in a manner likely to please the hand that feeds them (ie: save money.) Biased 'research' is readily available. Much of the current reform 'debate' has been fueled by publicizing extremely biased 'research' results. Just like any political poll - ask the wrong question, get the wrong answer. Health care is too important for that to become the rule of the day. Before ANY talk of seriously adopting CER influence can be considered, we should develop a plan for conducting the research in a transparent and credible format and get THAT infrastructure operating. Such a credible body of CE research does not exist today.
The improvement in the malpractice situation in Texas mirrors what occurred in Florida when the state reformed Worker's Compensation.I have practiced before and after the reform treating hand injuries and can testify that once you remove the financial incentives from greedy attorneys,things change dramatically.Congress knows this and they simply refuse to acknowledge the facts!
As for "one size fits all",this reflects the simple minded attempts Democrats and the President are calling reform.They know we have the real answers to improve healthcare,but don't want our input due to their political support by lobbyists who will lose financially..
Here are some of my concerns about Comparative Effectiveness Research and Evidence-Based Medicine.
As you may know, there have been some concerns about the quality of medical writing, ghostwriting, and guest authorship of published research papers. Sen. Grassley has been looking into this issue. The upshot of some of this has been to cast doubt on the quality of some of the published literature available. While aspersions have been cast on the pharmaceutical industry in this regard, it has also been found that there are questionable publishing and research practices in academia which may be even more prevalent.
An additional problem is the increasing tendency of universities to issue press releases in advance of a published paper, which can result in journalists, policymakers, and others writing opinion pieces and making decisions based on the superficial information in the press release, and not on the actual published data, which may not appear for another month or more.
Consensus guidelines, put together by experts in a given field, are useful--up to a point. They will not be useful if they are mandated by bureaucrats, and are based on single studies. It should be kept in mind that with every disease state, there are outliers. Many published studies exclude certain subjects, in order to keep the data from becoming too unruly. This, however, does not reflect "real world" patients. Treatment guidelines that are based on published literature will not reflect the "real world," yet these are the patients we must treat.
Please do not bind us hand and foot in our attempt to do so.
Sermo Doc 23, Rep. Michelle Bachman??? Are you kidding? That particular individual is borderline if you ask me. I don't think I'd put much stock in anything you think she can do for you or the profession.
I'm really disturbed by the number of physicians who are associating themselves with the far rightwing teabagger, deather, czarer, birther types. This will result in absolutely no good for the medical profession.
Forget who puts the demonstration together even if it's Godzilla!
If Doctors and Americans can get together and protest together at the Capitol and meet with their Congressmen, face to face, with cell phones/cameras, that can effect some change.
If you like the way our Socialist Govt. is moving, stay home and read Karl Marx or watch the Marx Brothers, your choice.
Senator, I am glad for your interest in health reform, however I am extremely disappointed in your biased "push survey". Please, reconsider who you ask to develop your questions next time. The questions are insulting. As a clinician researcher I can tell you that your question has nothing to do with CER. No physician would disagree that our goal is to offer the best quality care available, most physicians would agree that having strong evidence behind our decisions is optimal.
As all of us involved in clinical care can attest, health care (and sick care) reform is crucial. In a country with the resources of the U.S., one coordinated system of care, not linked to employment or income, available to all, is our moral responsibility. I am disappointed by anything less.
We already have comparative effectiveness research published every month. This is a beaucratic wolf in sheep's clothing and is not only trying to reinvent the wheel, but will also have a political goal of denying care and coverage for certain condtions and procedures.
We also already have Preferred Practice Patterns and published evidenced based medicine that are the backbone of competent care.
If the government wants to keep down costs, they should never have given excessive power to NPs, chiropractors, optometrists, etc. In my experience a NP seeing a patient with a mild corneal infection is much more likely to pan-consult the field with a immunology consult, infectious disease consult, and a heme/onc consult, in addition to the ophthalmology consult. It is idiotic, bad medicine, and very expensive. Chiropractors can order various imaging studies but lack the medical knowledge to A) know which test is actually indicated and B) are unable to correctly interpret them. This also adds significant expense and excess testing. Optometrists have very poor training beyond prescribing glasses and try to put every single patient in glasses whether they need them or not. There are millions of dollars in excess glasses each year that people don't even wear because they were not medically indicated. As California recently demonstrated, they are unable to manage glaucoma. If you want to cut down on costs, maybe you should start auditing chiropractor, NP, and optometrist claims first and see how much waste is there and see how much a royal mistake Congress made by ever granting them additional privileges.
Having clear utilization guidelines would be preferable to the byzantine system of insurance company clerks who practice medicine at their computer screens. Let's be clear- the current system of private insurers is not working. The government needs to be involved. At least we can hope that the government will care about the health of its citizens.
C'mon--the wording is so biased! I assume your staff wrote these questions. I've capitalized the offending phrases:
"What impact would ONE-SIZE-FITS-ALL coverage decisions FROM WASHINGTON" and "how effective would ONE-SIZE-FITS-ALL coverage decisions FROM WASHINGTON"
Sen. Cornyn's staff--Check out the story from today's NPR's Morning Edition ("GOP Strategist: Obama Honeymoon Is Over") in which host Steve Inskeep asks GOP political consultant Mike Murphy about poll numbers showing the majority of the public supports a public option. Murphy's response was "you have to be very careful. Polls that test hypotheticals--would you like a helicopter in your back yard every day that'll take you to work in 4 min--you can get a very good poll number..."
So...can you show us where in any of the draft legislation does it say there'd be ONE-SIZE-FITS-ALL coverage decisions FROM WASHINGTON?
Did you think you could pull something like that on Sermo?
I think one of the big pushes towards CER is that we have been unable to date to get it together ourselves. We do have conscensus guidlines which have taken years to formulate and put together. But there are two problems: there are many other questions unanswered - which could REASONABLY be answered. Note, I am not talking about things that have to do with individual variation in patients and clinical scenarios. I am talking about expensive treatments, procedures etc which are done just because that's how you trianed, that's what will make you more money, that's what you like, but it may not be better than the other cheaper more efficient method, you are just too lazy to figure out which is best.
The other problem is that even though we have these well thought out guidlines, they are really often not followed. I see this as primarily the fault of the individual physiciancs, but there are many things that make it hard for the informaiton to be disseminated. So even thought we know a few of the answers we are not even following that.
I don't think CER in its essence is to creat one-size-fits-all medicine. It's to find answers so that we can be more respobsible, efficient and cost effective physicians. The government wouldn't have to impose this on us, if we were doing it well ourselves. And we are not. The information needs to be gained.
And there are probably some areas, some, where it would be appropriate to have some structure we are not really allowed to stray from. But this only works to a point and we must never loose our ability to make the complex decisions required in each clinical situation.
What a ridiculous biased poll. Now the Sermo physicians will be used as GOP talking points propaganda. We are being used by the Right to scare the public. We all know that health care must be reformed yet I fear Sermo docs will be used as ammunition to block much needed progress.
I am an ob/gyn in connecticut, and we desperately need tort reform. Example: patients come in asking me for a CA125 test to "screen " for ovarian cancer (they get this stuff from the internet.) I explain it is not a screening test, but the patient insists. And I order it. Why? Because in 5 years, if she is in that 1.4% group that gets diagnosed with ovarian cancer, and the next thing you know, I am in front of a lay jury, and the plaintiff's lawyer says "This patient died because Dr. M didn't order a blood test" well, guess who the jury is going to believe? I can give you countless examples of tests we order , Caesarean Sections we do, so we can sleep better at night. If we follow established guidelines, we should be safe from litigation, but in the current system, we are at the mercy of plaintiffs lawyers, and juries of our "peers", lay jurors who never went to medical school, and in my own personal experience,, who never even went to college!
Senator, Thank you very much for your time and interest. I agree, there is a lot of money to be gained in liability reform and decreased defensive medicine. Since the NIH all ready is doing research in medicine another arm of research seems to be a duplication and I am not sure what exact measures they will be researching. Concensus guidelines can be helpful when discussing treatment options with your patients. But frankly, I have several patients who will continue to disagree with them and do not do the recommended treatments I suggest for what ever reasons. Often times it is from distrust of the pharmaceutical industry and a preference for "natural" remedies or a lack of an ability to afford such treatments. The thing that scares me with big brother looking over my shoulder is that if those individuals do not do the recommended treatment, then I am somehow deemed a poor physician. That in turn will make me what to discharge such patients from my practice, which seems like an even worse outcome given the limited amount of family physicians availble these days. But that is another topic....(hopefully you will get to that one too)
Agree this is a biased poll. Ick. I'm not opposed to thoughtful tort reform but doubt it would bring the savings needed. Now, on the other hand, an approach to health care administration that simplifies it and reduces the ridiculous amount of busywork built into the system would make more sense. Compare the low administrative costs of Medicare, including physician office admin costs, to the high costs of commercial insurance. I do not object to thoughtful restrictions on my practice (like generic prescribing mandated when generics are available and a restrictive formulary, as simple examples) as long as they are, again, thoughtful, and have an appeal process that respects that each patient may have individual modifying circumstances and permits care outside usual guidelines when clearly appropriate.
Agree that this poll - and prior ones - are biased in the very nature of the wording. Comparative Effectiveness Research is long overdue - and should be extended by the Congress to include the approval process for new drugs. Amazing what the development of new me-too drugs (with fresh patents) does to the overall cost of medicines and thus the healthcare system.
It's time to stop the rhetoric, and get both parties to agree that universal health coverage is overdue, and get to work on an acceptable compromise that gets it done (in today's news - the proposed Republican Senate plan will cover 3Million uninsured - leaving 37million still uninsured - is this a serious approach?)
If I were sued, I wouldn't place much faith in a CER report to be admissible evidence in court and to help me if it was admitted. The plaintiff's attorney has only to say "but my client had the following special circumstances..." and you're done for.
There are 2 reasons why money is wasted in the system: 1) defensive medicine, and 2) patient demand. CER might help with the patient demand side - you can say that something is of no proven value, maybe they'll believe you.
The best "brake" on the #2 problem above is for patients to have to pay for tests with no proven benefit. Well, then you get into the argument of "proven benefit". So don't worry about that. Just make the patient responsible for the first $5000 of medical spending through an MSA and they will apply their own financial caution.
What gets every cash-pay patient's attention: "In my opinion that test is not worth your money right now." They're grateful, not angry, to hear you say that.
I would like to add to Sermo Doc 19's list:
Bring back balanced billing for Medicare patients. The Gov't can't afford to pay a reasonal fee for physicians' services; so let us get the balance from the patients.
All physician contracts (M'care, M'caid, Mismananged care) should have a COLA. However; when there is no cost of living increase, I wouldn't expect an increase Mr. President.
Agree the language of the questions used here is clearly designed to steer replies to the negative ("one size fits all" versus "Would evidence based, peer reviewed best practice recommendations help the average physician in his daily practice, and/or help avoid baseless malpractice litigation?"). Please write questions in a neutral manner if you want meaningful data from them.
It is quite clear from usage elsewhere (e.g. NHS's NICE) that implementation of best practice recommendations can help control costs and still allow clinical flexibility. It's also clear that tort reform is another useful arrow in the quiver for reducing total health care expenditures, and should not be ignored. We'll ultimately need all the help we can get to bring our per capita costs anywhere near where we need to be in order to keep the deficit manageable. Implement both.
Dear Mr. Coryn:
Thank you for requesting our input into medical care decisions.
1. Defensive medicine is a huge problem, Any enjoyment of my specialty has been taken away by the giant litigation elephant peering over my shoulder at every film I read. It is miserable, and does result in a huge number of unnecessary follow-up exams as part of the trial lawyers' creation of CYA medicine. When are politicians going to stand up to these bullies, who control by finance and fear (true terrorism)?
2. Practice guidelines will only serve to create more paperwork-by which physicians are already completely inundated. Trial lawyers will use these guidelines to try to trip-up docs and deny necessary care to the patients that need it. MD's earned their degrees because they have the intelligence and training to make logical, informed, medical decisions-themselves.
The cost of health care will never come down until effective Tort reform is passed. Comparative Effectiveness Research is a veiled attempt to do two things:
1. delay any real action on Tort reform 2. eliminate as many primary care physicians as possible, replacing them with PAs and NPs.
I realize that the second point is controversial and not inherently obvious, so let me explain. If enough of this Comparative Effectiveness Research is done, there will be protocols for the treatment of everything, eliminating the ability of doctors to use their own judgment in the treatment of patients. If you do not need someone with a doctor's level of training, why pay for one? There is a projected shortage of PCPs in the near future and the NPs are already lining up to take our place. This is just another opening for them to exploit.
Thank you so much for coming here. I am a practicing dermatologist. As an undergraduate, I majored in applied math / risk assessment at Harvard.
There are vast amounts of money to be saved by conducting comparative trials of treatments. In my opinion, Congress can substantially reduce health care expenditures via comparative trials with a single page of law.
That page should require that all new medications and all new medical devices be compared against existing best therapies. Current FDA studies on most new medication are done vs. placebo. We do not need to know whether a new $3,000/year drug is better than a sugar pill. We need to know whether it is truly better than the $200/year generic. This will cost Congress nothing. The drug companies would simply have to change their trials, adding a comparison arm. No additional regulation would be required. The FDA already has rules in place for trials.
A concrete example from dermatology: Altabax is a topical antibiotic recently approved by the FDA. It is prescription and costs $100 for 5 grams. For comparison, Polysporin is an over the counter topical antibiotic that costs roughly $5 for 10 grams generic. Altabax has many studies showing it kills bacteria at lower concentrations than other topical antibiotics. Gram for gram, it is more effective. So, many primary care doctors and dermatologists prescribe it. But it is a scam. The actual amounts of antibiotic used in these topicals are so high that differences in the lab do not matter. Polysporin should work just as well as Altabax on patients.
Had the FDA required Altabax to be compared to Polysporin instead of placebo, Altabax very likely would have shown itself to be merely equivalent to Polysporin. And therefore, we doctors would rarely prescribe it. This would save Medicare and Medicaid millions and millions of dollars a year. Altabax, by the way, is a minor drug, a drop in the bucket. Many of the big drug companies don't even bother with topicals like Altabax because they don't make enough money to count.
If you apply this same rule to major drugs, like the antidepressants, cholesterol-lowering drugs, and blood pressure treatments, you would find that many of the "new" and very expensive drugs do no better than existing generics. Medicare and Medicaid would save many billions without changing outcomes. These billions would be saved because we doctors would not prescribe nearly as many new high-priced equivalents of good, inexpensive, generic medications.
I speculate that this would generate a huge political fight, because vast profits are being made on these drugs. However, it is hard to fight a single sentence that the public can understand:
"When possible, the FDA shall require that new medications seeking approval be compared in clinical trials against the best approved medications that are already on the market."
I will put additional comments on other topics in separate posts. Thank you again for your interest Senator. It is truly appreciated.
I agree with all of Ramstrong's points and want to add an additional angle on the tort reform issue.
In medical school we were taught how to make a diagnosis by using our clinical skills and turning to more specialized testing if we needed more information to make the diagnosis. When we got to residency, I was shocked (and insulted) to find that we were being trained to give up our clinical skills and turn to expensive testing so that we would be able to defend all of our actions in court should a malpractice case arise.
To put it another way: In the current medicolegal system, even if we have enough information to make the diagnosis, we have to order the specialized tests to confirm that we are right just to fend off malpractice attorneys. This ends up costing up to ten times as much as simply treating the patient based on clinical acumen.
Please give a board-certified physician the right to rely on his/her clinical skills without the need for the practice of defensive medicine. You will save this country a fortune.
We don't trust Wasington but will listen to Mayo, Hopkins, and Pitt. Harvard has too much agenda intermixed with academia. Let's let NIH funding go to the trusted institutions and primary care docs to develop assistance for the lowly cogs in the healthcare system that happened to spend alot of time studying health. Then get out of the way as doctors and patients decide what's best.
How about comparative effectiveness research into how much trial lawyers contibute to our Gross Domestic Product?
Have any congressmen looked seriously at what chiropractors are being reimbursed for their "treatments" ( a massage by a massage therapist)? If we simply cut out that type of fraud, there would be plenty of money left to pay for real medicine.
Senator Cornyn,
Texas Medical Association and Texas docs put you on the Texas Supreme Court, your stepping stone to the Senate. Since then, whenever we have asked for your vote on issues important to medicine, you have walked away. When you start supporting us we will believe you are our advocate. Remember we have enormous influence in our communities (that is how you won the Supreme Court election) and we are paying attention to your votes.
Sen. Cornyn,
I wrote you a couple of weeks ago about this issue and still have not heard back. I am not a member of the AMA, but did not appreciate your criticism of them in regards to their approach to medical concerns. From that article I read in AMA News, it did not sound like these issues concern you at all, so this forum is a surprise. You also seemed to have no trouble voting against the Senate SGR repeal recently.
Tort reform is indeed an important component in the increase in medical costs, but it is not the only one. I agree that practice guidelines sound ominous and time consuming if they are implemented like other government initiatives. If you are so interested, why don't you get involved to see that it is done differently this time. And vote the way you really feel on SGR instead of twisting with the breeze like you did in 2008.
Just a small point for those of you who are commenting on the recent Senate vote on the SGR. Do some in depth reading about how this bill, S.1776, came into existence and why. S.1776 was a pure political diversion to try to "hide" 247 billion dollars from the Senate health reform bill. It had nothing to do with what is or is not correct about the way Medicare calculates payments to physicians. The SGR needs to go. But, it should go the way of a comprehensive reform of Medicare, not for political expediency.
Could someone show me where in the Constitution the Feds have any authority to do what they are doing and planning to do? We seem to have forgotten that little old pesky document which was written to PREVENT the government from doing what they are doing now. Perhaps it is time to step back and ask ourselves "do we really want the Feds involved at all?" It may be simplistic, but we are falling into the same trap that began before Medicare started. Senator, go read the Constitution and the Federalist papers then come back and talk to us again.
Dear Senator-
With the above comments you are hearing the frustration and anger from physicians who have been pushed around and ignored. The problem with the system is too much money made by certain groups(insurers, pharmaceuticals, hospitals, and medical device makers,etc). Physicians have had eroding salaries and increased workloads for years. The doctors are fed up and are now forced to retire or change jobs in droves. If you want to ration care, you will do it as there won't be docs to see patients. If you want to mess(read f***) with anyone, please do it to the folks who have made a killing off the system.
The "questions" you asked are not valid. You're not at a rally of the same cowardly dim-witted yokels that you and your neo-con cronies terrified into voting for you and your ilk. The majority of the American people are smart enough to see through your lies. It's no longer just the few liberals that have been brave enough and patriotic enough to stand up to the likes of you for years. You've proven to be nothing more than an insurance cartel minion and Obama and Pelosi will bring you down.
We entrusted you with upholding the Constitution. I believed in the checks and balances to keep from getting far off course. What happened? You are very far off course. Do you really think I find humor in the hiring of a speed reader to unintelligently ramble all through a bill that you signed into law without knowing what it contained? I do not.
It is a mockery of the responsibility I have entrusted to you. It is a slap in the face. I am not laughing at your arrogance. Why is it that I feel as if you would not trust me to make a single decision about my own life and how I would live it but you should expect that I should trust you with the debt that you have laid on all of us and our children. We did not want the TARP bill. We said no. We would repeal it if we could. I am sure that we still cannot. There is needless urgency and recklessness in all of your recent spending of our tax dollars.
From my perspective, it seems that all of you have gone insane. I also know that I am far from alone in these feelings. Do you honestly feel that your current pursuits have merit to patriotic Americans? We want it to stop. We want to put the brakes on everything that is being rushed by us and forced upon us. We want our voice back. You have forced us to put our lives on hold to straighten out the mess that you are making. We will have to give up our vacations, our time spent with our children, any relaxation time we may have had and money we cannot afford to spend on bringing our concerns to Washington . Our president often knows all the right buzzwords like unsustainable. Well, no kidding. How many tens of thousands of dollars did the focus group cost to come up with that word? We don't want your overpriced words. Stop treating us like we're morons.
We want all of you to stop focusing on your reelection and do the job we want done, not the job you want done or the job your party wants done. You work for us and at this rate I guarantee you not for long because we are coming. We will be heard and we will be represented. You think we're so busy with our lives that we will never come for you? We are the formerly silent majority, all of us who quietly work, pay taxes, obey the law, vote, save money, keep our noses to the grindstone... and we are now looking at you.
You have awakened us, the patriotic freedom spirit so strong and so powerful that it had been sleeping too long. You have pushed us too far. Our numbers are great. They may surprise you. For every one of us who will be there, there will be hundreds more that could not come. Unlike you, we have their trust. We will represent them honestly, rest assured. They will be at the polls on voting day to usher you out of office.
We have cancelled vacations. We will use our last few dollars saved. We will find the representation among us and a grassroots campaign will flourish. We didn't ask for this fight. But the gloves are coming off. We do not come in violence, but we are angry. You will represent us or you will be replaced with someone who will. There are candidates among us who will rise like a Phoenix from the ashes that you have made of our constitution..
Democrat, Republican, independent, libertarian. Understand this. We don't care. Political parties are meaningless to us Patriotic Americans are willing to do right by us and our Constitution, and that is all that matters to us now. We are going to fire all of you who abuse power and seek more. It is not your power. It is ours and we want it back. We entrusted you with it and you abused it. You are dishonorable. You are dishonest. As Americans we are ashamed of you. You have brought shame to us. If you are not representing the wants and needs of your constituency loudly and consistently, in spite of the objections of your party, you will be fired. Did you hear? We no longer care about your political parties. You need to be loyal to us, not to them.. Because we will get you fired and they will not save you.
If you do or can represent me, my issues, my views, please stand up. Make your identity known. You need to make some noise about it. Speak up. I need to know who you are. If you do not speak up, you will be herded out with the rest of the sheep and we will replace the whole damn congress if need be one by one. We are coming. Are we coming for you? Who do you represent? What do you represent? Listen. Because we are coming.
I am really discouraged by the way this and so many Sermo "surveys" operate. If you want an opinion, please make a survey that gets a real opinionm not one conflated with leading verbiage that drives an answer. You are dealing with intelligent, well educated folks here. I am tuning out from Sermo, not because I disagree with your basic stances, but because I don't like to be manipulated. I have serious issues with the Dem's health reform, but I do strongly believe in comparative effectiveness. It frankly should be a cornerstone of the Republican bill. I also believe that these kind of guidelines could do much to protect someone from malpractice, but that is too time consuming to go into. Now, Sen. Cornyn, I am a Texan. I don't live there right now, but I am relocating my company there soon and will be living there in time for your next election. I lean Republican as do most of my Texas relatives. We tend to be independent spirits and vote that way. I will be sharing your association in this very misleading "survey" with them. I hope you will distance yourself from this travesty.
For a good example of "one size fits all" health care, you need look no further than your neighboring state of Louisiana. For those who do not remember, Medicaid was begun to give the rest of the country what Louisiana provided with its Charity Health System. The system works, but is indeed rationed care, as anyone who was around during hurricanes Katrina and Rita will tell you. During that time, the 8 Charity Hospitals in the state were reduced to 5 in a matter of 3 weeks. Charity New Orleans ceased to exist, and the moment the computer room in the basement of "Big Charity" lost power, ALL patient medical records throughout the entire system were lost--there was no back up, there was no mirror site. I know this for a fact, because I had a solo practice at one of the surviving Charity Hospitals and remember the moment wie lost all access to patient information. It took weeks for the IT team members across the state to recover and rebuid this.
Anyone who is honest will tell you that equipment, resources, etc, were not equal throughout the system, and that care in such a system is by necessity rationed. Those with more clout get more, and others will go wanting. Charity New Orleans had a new MRI which of course became useless after the flood. My hospital didn't even have a CT scanner capable of diagnosing pulmonary emboli, and this was in 2005. Nuclear medicine was contracted out and not an on-call service. And all of a sudden this tiny hospital was serving a population greater than just the geographical area. This is what happens in a government run system. No one is turned away, but it's hardly speedy or efficient..
Senator Cornyn, Louisiana Governor Bobby Jindal has more experience with this type of health care than anyone in the country. If you are looking for information, look no further than the state next door, and the governor's office. As a former head of the Louisiana DHHS, Bobby Jindal can provide you all the information you need, including what happens when disasters such as Hurricanes Katrina and Rita decimate parts of the state as happened in Louisiana just 4 years ago, and how this impacts health care delivery in a "one-size-fits-all" population. He will know the costs, the pluses, the minuses, the strengths and the weaknesses of such a system better than anyone I can think of, and surely better than Harry Reid or Nancy Pelosi.
The goal of the Democrats is obvious: create protocols for tick box medicine, then one can have non-physicians such as nurse practitioners and other lower level providers give a lower level of care while denying the higher level of care that only the more highly trained and experienced physicians can give.
Other countries have tried this. It hurts the patients.
We all use constantly changing guidelines in our practices. Most of us are sharp enough to recognize when we need to deviate from the guideline in order to help the patient most effectively. In fact, that is how medicine advances and why one can receive the highest quality of medical care in the history of mankind only in the United States. Of course the statist totalitarians would want to take that away.
Consider, if you will, the frustration of the doctor who sacrificed so much for so long in order to be able to help patients, only to be forbidden by the insurance company to do what is best for a patient because their high school graduate who can spell neither the condition nor the needed procedure can't understand the patient's problem. Now multiply that frustration by thousands. That's government run tick box medicine. We physicians need less interference as we help patients, not more.
If American medicine had always used such tick box medicine protocols, we would still be receiving blood lettings and leeches -- at the barber shop. No one would be washing their hands. Millions of women would still be dying in childbirth.
Of course, it seems that it might be cheaper. It wouldn't. Not only would the individual whose condition is unusual or less common be hurt, the failure to treat the patient optimally would lead to more illness and more cost, both in terms of more medical treatment and reduced productivity.
Every specialty organization currently uses and updates best practices guidelines -- as recommendations for the common situation. How do bureaucrats who lack the training and experience know better?
In those cases where their protocol fails, will the bureaucrats pay the malpractice claims? After all, they are now proposing to practice medicine -- the second they begin to enforce their protocols.
Please note that we already have some physicians who never deviate from certain protocols because they believe themselves incapable of doing better. This minority of doctors already practice a lower level of care. Increasing their numbers to 100% of our field will hurt patients and kill innovation.
Thank you for coming here and getting input from practicing physicians. With all due respect, having politicians in Washington, who are for the most part backed by unions and lobbyists, redesign 1/5 of the US economy is a travesty that is being forced on the American people under the guise of "taking care of the 47 million uninsured". You and I both know that number is hugely inflated, and adds in illegal immigrants, who should basically be shown the way home, not given more free benefits. It also includes people who 'choose' to not have insurance, and if I remember correctly the USA is still a free country and as such should not have the government force policies on the people. Period, end of story. Additionally, taxing the people who actually provide jobs and produce in this society to pay for those who don't is not a way to foster excellence, or create jobs. It is a way to drive down excellence, reduce jobs and foster mediocrity. When is Washington going to remember what made America great? Self reliance. Self determination. Personal responsibility.
Having gotten that off my chest, let's talk about comparative effectiveness. While in theory, this sounds good. In practice a 'one size fits all' approach to care is just a way to subvert the doctor/patient relationship with government edicts. Additionally, these studies are a perfect petri dish for more government corruption. Doctors and patients, working together as a team to improve health, has worked effectively in our practice for 25 years.
A large part of my practice is teaching patient how to care of themselves, and making sure that they do it. I have helped over 1500 people turn their lives around, lose weight and get off BP/cholesterol meds and reverse their diabetes. How's that for reducing costs? Imagine if doctors were able to put the efforts into getting people healthy, rather than just managing conditions. What would that do for cost containment?
True cost reduction will occur when their is tort reform, and allowing insurance companies to compete across state lines for business. Putting doctors on a Medicare fee schedule will result in fewer doctors. I have been treating people over the years who for one reason or another can't pay their bills, usually due to some sort of financial hardship, but I can't write those services off of my taxes. How about allowing doctors to do that? I am sure that most of us would be happy to take care of these people if we could write those services off, and it would not cost the tax payer one cent. There is your coverage for the 'real' uninsured.
There are a great many 'real world/free market' solutions to health care. The answer is not in Washington, with politicians.
All these Republican senators paying so much attention to little old me just makes me blush. It reminds me of that prom date when the boy keeps assuring the girl that he will respect her in the morning. Regardless of gender, we all know how that turned out. Where was all this attention during the last eight years, when Republicans had the votes to enact tort reform, and fix the payment formula?
There is no doubt, that we are the flavor of the month because we offer an opportunity to make Obama look bad. I don't mind Obama looking bad, but he seems to be able to do that all by himself. Only the most naïve of us believes that the Republicans care about the welfare of physicians or their patients. They won't respect us in the morning. As an excellent example, remember that Sen. Cornyn is a lawyer, a former judge, and a former Texas Atty. Gen. He does not need to know what a poor malpractice environment does to physicians. He already knows. His inquiry is for the most part, designed to draw attention to himself, and portray himself as a man of the doctor folks!
That said, his question has been repeatedly answered by many more articulate people than myself. No one knows how much money could be saved in a healthier malpractice environment. There has been ethical slippage amongst physicians, which although caused by a poor tort environment, as well as a dismal reimbursement environment, may not be reversible. When it became okay to order unnecessary tests, and diagnostics, to protect against possible future litigation, it was one small step over the line that made it possible to order unnecessary tests to increase reimbursement. To be sure, there have always been physicians who did unnecessary testing, for example CBCs and chest x-rays on every patient , but it never happened on the scale that it does now. In my community of 20,000 we have three group practices that have all become experts on churning every possible dollar out of every patient. This is happening because of our dismal reimbursement environment, but it became ethically okay because of defensive medicine. No physician, on any survey, will admit that that's the case. No cardiologist will admit that he has done unnecessary angiograms. No orthopedist will admit to doing joint replacements that he knew would not help the patient. These are the times in which we live.
One of the writers above noted that In capping malpractice awards we are not reforming the tort system. The system continues as it always has. It still rapes every physician who is accused of malpractice. No physician who has been accused, regardless of the outcome, practices the same way afterward. True tort reform would require a paradigm shift in the way patients and the legal system think. Frankly, I don't believe we have the ethical environment amongst politicians, or the intellect amongst politicians, for that to happen. Without meaningful change in the tort environment,defensive medicine will continue, and those savings will never be appreciated.
As to comparative effectiveness, it is another attempt to turn medicine into a cookie-cutter business. This started when Medicare attempted to adapt the work of W. Edwards Deming on total quality management. Deming, who was an expert on tweaking process to get maximal effectiveness, was never consulted on applying his work to medical care. At one time, he did comment that would be a very difficult thing to do. Some of his work has been adapted to shorten length of stays on, for example, joint replacement surgeries. At this time, there is ongoing research in attempting to eliminate recidivism in COPD patients. I've not seen any outcome. There does appear to be some utility in the work, on a microcosm level. The idea of applying it on a macrocosm level is horrifying. It would be enormously expensive, would require intellectual leadership that does not currently exist in our government, and it would require a total commitment on the part of physicians, patients, and even lawyers to accomplish.
By the way, did anyone notice that the whores that run AA RP just sodomized their own members by endorsing the House health care bill. Just amazing!
CER has the potential to improve both treatment and diagnostic approaches. The risks are that these government sponsored entities will draw conclusions which are premature, generalized too widely, or rigidly enforced. Our politicians have little sense of the immense individual variation which exists among patients. This variation limits the utility of 'evidence based medicine' standards.
Again I thank you for coming here. I am the dermatologist with the Harvard applied math/risk background.
You ask about defensive medicine. This is a huge problem for doctors. The issue is we cannot guarantee good outcomes. Even with a very harmless-appearing mole, for example, no dermatologist can know for sure that it won't become a melanoma. So we manage risk with every decision. If the risk appears miniscule, we do nothing. But often the risk appears merely "very low" or "low," in which case we must think about whether we could get sued if we don't order the full workup.
Take a patient who comes into the Emergency Department with a headache after falling and banging his head. The doctor assesses him and decides the chances of him having a brain bleed is "too low to justify a head scan." What happens if he releases the patient without a $2,000 head scan and the patient has a bad stroke from a brain bleed? The doctor will get full blame for being "wrong." Well he wasn't wrong. He assessed the risk as "too low to justify a $2,000 head scan," not "zero."
Knowing he could get sued if the patient has a rare bad outcome, the doctor starts thinking about the patient. Is the patient the suing type? Is the spouse demanding a head scan? If so, then many times the doctor will order that head scan. The head scan does not benefit the doctor financially: he neither makes nor loses money when he orders one. But he does benefit from peace of mind, knowing he is now in the clear should a hidden brain bleed cause problems later.
Fear of lawsuits changes what we do. An example from dermatology:
If you take 20 moles off 20 teenagers' backs today and send them in, many of those moles will be called atypical by the pathologist who reads the slides. If you took those SAME moles and transported them back to 1990, the 1990 pathologists would call far fewer of the moles atypical.
In other words, the pathologist's definition of what is "atypical" in a mole has changed radically. Minor features that used to be considered normal are now called atypical by many pathologists. From a numbers perspective, the number of moles on all Americans didn't change much, but the percentage of those moles that would be called atypical perhaps tripled or quadrupled (my guess, not studied numbers).
What changed? What happened was a couple pathologists got sued when "slightly atypical" moles turned into melanoma and killed people. The pathologists effectively called the risk "very low, and not justifying cutting out a big piece of skin." They were correct. Bu the risk was only "very low," not "zero." Since they looked at millions of moles, it was bound to happen that a few "very low risk" moles became deadly melanomas. This is similar to playing Powerball: if enough people buy tickets, someone will eventually win. The lawsuits were lost, and the pathologists got nervous. What if they called a mole ok, but the pathologist who reread the slide for the trial lawyer said "No, this is slightly atypical, so he should said to cut it out if it comes back."
As a doctor, after you lose a night or two of sleep over this, often you just go with it and start calling more moles atypical.
Again, nothing changed except the pathologists became more afraid of getting sued, and then starting calling vastly more moles atypical.
So what was the result? Far more moles are getting biopsied now. Far more biopsies are ending up with the dermatologist having to go back and cut the moles out. This should never have happened. We have better clinical diagnostic techniques than we used to. Using a handheld microscope called a dermatoscope, we dermatologists are now considerably better than our colleagues were 20 years ago at figuring out which moles are bad and which are ok. But we do many more biopsies now. Why? A few lawsuits were successful, we became afraid, and we know that even though the dermatoscope says it's ok the pathologist will probably call it atypical. So I ask myself, "Do I want to risk bankruptcy and losing everything I have worked for for 20 years over this mole, even if it is a small risk?"
Comparative Effectiveness is research and should be handled as all research if government sponsored - at an independent agency beyond the reach of politicians - perhaps at the NIH staffed by independent non-political researchers. The same liberal folks calling for the government to run this have had a field day running Big Pharma out of the similar research due to inherent bias. The folks who support this now had a very different attitude when stem cell research was held to a political standard. Just suppose 10 years from now (although based on Tuesday it could be a lot sooner) we have conservative congressional leaders who certain lines of research over another - the outcry will be incredible about the "politcization" of comparative research.
Tort reform has to be included now or it never will be.
Sermo Doc 23, Rep. Michelle Bachman??? Are you kidding? That particular individual is borderline if you ask me. sgmorr gets his instructions from MSNBC, because anyone that has actually heard Rep. Bachman talk knows she is informed and very bright.
I am already constrained by many formularies and cannot give the patients what they need if they do not fit into the "committee's idea of what is most effective or should be effective " for a particular condition. Too much time has to be spent explaining to the insurance company why the patient needs different care. Expanding this type of thinking and creating a bigger beuracracy to tell us how to treat is a nightmare!
There are already organizations establishing "best practices" to treat illnesses and improve patient safety. Keep the feds from becoming more involved in the practice of medicine than they already are!
If your are truly interested in having a health care system that benefits the people of the country, and requires the least expenditure of GNP, please read the above comments carefully. Most of these suggestions have a tie to realities that are being ignored in the current partisan debate.
1. Statistics deal with populations, not the individuals within that population. Guidelines / protocols / "Evidence Based Practices" provide checklists of what should be considered, and more importantly when to change course and consider alternatives: a) Individuals need care for their individual problem. There is no way to know in advance whether an individual patient fits the established paradigm. b) Medical knowledge expands from investigation of exceptions, not repeating failed solutions. I won't comment here on other segments of society.
Pre-flight check lists do pilots little good after takeoff when something goes wrong. The investigation of exceptions must be encouraged, and financially supported. The time and effort required to thoroughly deal with a patient doesn't fit into one ten or fifteen minute office visit.
2. Tort Reform is essential! Add the Trial Lawyers to the list of people with immense profit from the health care budget with no actual responsibility for providing that care. Note, that if everyone's health care needs are covered by a universal coverage system, injured parties, whatever the cause - auto, medical, or negligent sidewalk repair - will have mo medical care cost requiring compensation. That leaves compensation for lost income and property, and prevention of recurrence at issue. Surely, these determinations are not best made in court, or when extraordinary judgments compensate attorneys far more than the injured, at the expense of the insured - premiums go up. Insurance companies are in business to make profit and pay executives.
3. The least expensive per capita cost for health care requires that the entire cost for the US population is divided by the number of people in the population. That should be the percentage of GNP allocated to health care. There can be no profit in that for anyone without direct responsibility for delivering that care, though certainly various models for providing the care could compete for the available funds, as long as there is open participation, with no discrimination regarding the people covered in a model.
I sincerely hope my thanks for your consideration of our views are not wasted. I've become quite cynical about the entire political process, watching campaign accounts growing at the expense of a realistic assessment of what the country needs.
will tort reform save the "healthcare system" money...probably not. we have been teaching "defensive medicine" for the past 20 years. so that wont change, but will help insurance premiums. as for comparitive effectiveness research i agree with the outehr that letting the gov run this is doomed to fail. the insurance co with so call medical/surgical directors still deny, deny, deny. they have to to stay a float. we need to keep all non-physicians out of our offices and charts.
Comparative effectiveness research is fine if done in, by and for the private sector. However, in the context of the healthcare reform proposals being currently discussed (HR 3200, Baucus, Pelosi) comparative effectiveness research is a *sure step* on the way to rationing. It will be used to politicize research and deny treatment. The bureaucrats funding such research specifically want to decrease costs, and therefor want to show that expensive treatments are no more effective than cheap treatment or no treatment. This will NOT be objective research.
Have to echo much of what has been said above. But, I also want to add something new. If you want a template for tort reform, do not look at Texas, look at Indiana. Years ago, Indiana instituted a system that actually worked. It reduced the number of lawsuits!!! This was shocking, unique, and amazing. It kept malpractice premiums down in the state for a decade, but it infuriated the trial lawyers.
When the Democrats took over in the late 80's, they proceeded to dilute the existing law's power. They openly chastised the medical panel for ruling in favor of physicians, and they eased access to the pool money. The net result is that Indiana's terrific system in the 70's and early 80's is not nearly as effective as it once was. It is still better than any other state right now, but Indiana's experience should be instructive for everyone. Even when you get a good system in place, it requires continual vigilance to protect it. The Democrats and the trial lawyers tore down something that worked very well because they didn't want anyone else to adopt it!!
Thanks for asking our input. We already have socialized medicine in this country- Medicare and Tricare. We need RATIONING yes I used that word to keep a lid on the budget for those folks whose health care we are paying for. This needs to be done with some science and support and not be knee jerk- Oregon's system of allotting money in priority until it runs out is an idea. The UK's NICE is slow but official. Standards which could stand up in court- ie Medicare can no longer waste money on biopsies probably not needed, so the dermatologist is off the hook the 12/million cases when that was a mistake, would help and we need both specialist input and some fiscal supervision on that. Of course cardiologists will sleep better at night (and have more money) if every chest pain is cathed, dermatologists if every mole is biopsied, we family docs if everyone chats with their FP for an hour every three months. However we as a nation choose not to afford such thoroughness.
I have been a recipient and worker in the British NHS system, the US Army system, and still get my care through tricare on the economy. The Brits and the military families are better off than most Americans. I recently worked in an underserved underinsured rural area. I had folks dying to stay out of medical debt or because it was already such a burden on their families. The same reasons we have Medicare- it is obscene to let people die for want of money to pay for basic medical care- is true for those under 65. (You should hear how amazed and appalled British doctors are that we let Americans lose their home and their savings and go beg for pennies at the gas station or church if they get really sick.)
While you fiddle Senator ( you and your buddies on the hill ) Rome burns.
And yes a revolution is coming and many who would be as Senator Gracus said " I don't pretend to one of the people but one who is for the people" may be surprised.. the mob is fickle brother....look at the recent elections in VA and NJ
Look how quickly the GOP lost it's power by forgetting the principles of THE MAJORITY OF THIS COUNTRY!!!!
It's always a little too late and always a dollar short with yuall.....
We are not children
Senator and the vast majority of us are more intellingent than the " leaders of our country... what a joke...
To answer your question most of us spend our time practicing evidence based medicine already... we call it CME
How do " you" learn something new.... or is that really asking too much?
Abunch of old dogs doing the same old tricks only none of us find them amusing anymore....
I'll give you credit for bringing up tort reform and allowing us to sound off on the government trying to cram more crap dowm our thoats but some of us.. esp primary care could have used your help years ago when you and your crony's were cutting our wages..where were you then...
I'll bet you can't tell me how many docs went into Internal Medicine this last year....Senator Less than 200 That's right less than 4 per state..
Whose gonna take care your sorry $@$@#% when you get sick? a PA maybe some super bright NP?
Fix our reimbursement issues NOW!
Fix tort reform NOW!
Tell the rest of congress when they get an MD degree they can practice medicine.
We worked hard to acheive our expertise and we were not elected to practice medicine.....we earned the right.
"One size will never fit all in medicine" - every doc already knows that but no politicians have ever gotten the message. We are all genetically, biologically and physically different so we need individualized decisions often, not cookie-cutter rules. I'm a former Canadian doc where this adage has run the socialized system since 1972. If this comes to the US, "you aint' seen nothing yet" !!!
"Optometrists have very poor training beyond prescribing glasses and try to put every single patient in glasses whether they need them or not. There are millions of dollars in excess glasses each year that people don't even wear because they were not medically indicated. As California recently demonstrated, they are unable to manage glaucoma. If you want to cut down on costs, maybe you should start auditing chiropractor, NP, and optometrist claims first and see how much waste is there and see how much a royal mistake Congress made by ever granting them additional privileges."
I live in the DFW area of north Texas, Cornyn's home turf. As far as ophthalmologists go, they have made their own bed in increasing the business of optometrists. When cataract surgery was big time business, a person could not beg their way into an ophthalmologist's office for routine exam and refraction. They thought they were wasting their time. I know a retired ophthalmologist in town who sends his kids and grandkids to optometrists for routine exams for that very reason. I think that, as a group, ophthalmologists need to get their house in order before they go criticizing optometrists so freely.
And like it or not, when patients, make that clients, get used to getting fitted for glasses and contacts by optometrists, then they will be more inclined to seek care with these same providers for medical problems of the eye too.
As someone who has been sued 3 times and lost one I didnt cause... a 1 million dollar lawsuit for missing a alpha1antitrypsinase deficiency in a non-compliant, smoking, fireman (his wife is out of work lawyer who had sued 16 times before for injury that fact was inadmissible in court) complaint was delay in diagnosis for 6 months. Yes, I want tort reform. My crappy malpractice insurance paid lawyer missed the boat, total mess up, got switched mid stream, my insurance case manager got fired for leaking information to the plantiff's attorney, my second lawyer never found a defense expert witness up to one month before trial and so they told me to settle or the plantiff's lawyer would go after my personal assets after a jury trial in Cook County which is the land of the lottery for lawyers. 5 yrs of anguish over this. Ended up on sabbatical for a month near the end from stress. Man you have to experience it to believe what it is like to have you in a room with 10 lawyers asking what you were thinking and what happened 5 yrs ago with the 5 visits I had with this guy. They were all trying to trip you up so you take the fall. The total amount paid for his genetic disease that I didnt cause ...wait for it... 17 million dollar and his lawyer got almost 1/2!! I have sworn that one more lawsuit I am gone. 30 yrs of good care one lab done by the hospital reported to me as normal and it was not, not my fault but my fall. I now have a financial fortress built and will be in better shape but then they froze all my assets..nice.
The "questions" you asked are not valid. You're not at a rally of the same cowardly dim-witted yokels that you and your neo-con cronies terrified into voting for you and your ilk. The majority of the American people are smart enough to see through your lies. It's no longer just the few liberals that have been brave enough and patriotic enough to stand up to the likes of you for years. You've proven to be nothing more than an insurance cartel minion and Obama and Pelosi will bring you down."
How many radiologists does it take to make a diagnosis?
Answer only one but I need another study.
What is a radiologist"s favorite landscape?
The hedge..
All jesting a side just as the patholigists rendition of a path report goes on and on and on it is because if they put the complete diffential diagnosis they can't be sued..
Radiology is another example.....many times a simple nodule 7mm in a lung now becomes a CT every 3 months why.....?
Everyone here on this site knows why..
Real case
70 year old man with RA and chronic fibosis on xray of chest
Ct ordered to look for signs of RA lung
1 cm nodule LUL
BX positive for adenocarcinoma
Partial lobectomy
Cured right? N1T0M0
Dead 18 months later metastaic spread to chest wall..
The point? We are not God....
The Lawyers would like to portray us that we think we are......and make money off the suffering not only of the dead but of those who have given our lives to better the lives of those we serve... and yes it's not just a job it is a calling........
Back in the USSR
You don't know how lucky you are................ Senator
But when the old guard is gone...your newer docs are gonna check in and check out..
And you better hope your MI is during the first part of the year cause when you get to the office the sign might just say..................
"And yes a revolution is coming and many who would be as Senator Gracus said " I don't pretend to one of the people but one who is for the people" may be surprised.. the mob is fickle brother....look at the recent elections in VA and NJ
Look how quickly the GOP lost it's power by forgetting the principles of THE MAJORITY OF THIS COUNTRY!!!!"
Hey, the Dem in VA was not a good candidate and did not run a good race. In fact, many Dem voters did not turn out because the candidate abandoned some Dem ideas that he should have campaigned on.
Hey, how about the far rightwing radical in upstate NY who Palin, Beck and her ilk tried to foist on the voters. They even forced the mainstream Repub. out of the race. And the Dem won in a district that has been R for a hundred years. You're right, a revolution is coming and it's going to throw out all the far rightwing teabagging, birthing, deathing, czaring, 9/12 ing fanatics that seem to have come out of the woodwork.
We do not live in a homogenous country. We are not finland or sweden. Our populations demographics, age and needs will vary and are a fluid model. I am in favor of 'best' practice guidelines. But remember, they are only guidelines and are not an edict on how to practice.
Thie rationing of care can be decided upon on a state and county level based on where they want to put those dollars. The feds need to stay out of the states' way wrt delivery of care models. California has a different demo than wyoming or Idaho. Give the states the greater say and allow guidelines to be just that.
Doctors are not allowed to practice medicine. We practice in a lot of instances defensively and access to and approval for studies impede that ability. The system needs change- I would challenge any industry, congress included to take a 25% pay cut and still remain in practice. It is rediculous to say that these issues are not intertwined.
The govt will effectively water down care and the bewildered public wont know the difference. They are not at fault. Insurers and physicians are to blame for that lack of insight. I always go out of my way to instruct what the consequences of treatment or lack there of is.
The "quiz" is a good example of push polling - giving the answer in the question. No proposal currently sets up a one size fits all panel. The proposals may encourage actual clinical studies on effectiveness (remember arthroscopic sandpapering of the knee joint which turned out to not withstand a clinical analysis). We should only be doing what works. A real problem currently is the obvious GOP strategy on the table: vote no on any issue that might benefit Obama and ignore the consequences of such a strategy. Or - the country be damned - the party Uber Alles.
David Franzus, all kidding aside. But don't you think that a very major reason that many tests are done is that the patients and their families demand to be diagnosed and treated? They want to find out what's wrong and want to get healed. And don't you think that many doctors really want to find out what is wrong with the patient and that sometimes diagnosing is difficult for the very reason that we are not "all knowing." You cannot just argue that all redundant, thorough, and perhaps unnecessary testing is done for fear of being sued.
And don't forget the huge amount of for profit testing that is done and encouraged by the owners of big time medical equipment.
Sermo Doc 20?????
My parents came to the US not for a better life, but for the opportunity for a better life. When you kill the desire, want to excell you stifle creativitiy and entrepreneures who look for ways to re-invent the world. This is the social agenda that has been forced upon us. You are effectivley taking away our 'opportunity' for a better life.
Sermo Doc 74 and gesharon, I love your posts! They are full of passion and anger, and they are genuine. I have been mad for years, and have had difficulty dealing with the massive APATHY of our profession. We have been abused because we are so in control of our emotions. We refuse to explode. It is a function of our personalities and training. When you face life and death crises on a daily basis, you rein in your emotions because they can cloud judgment.
But, it is time to get MAD! As David said, "When they get an MD, they can practice medicine."
The internet may prove to be valuable as a way of reaching and uniting physicians. Apparently, SOME Senators already see the benefit of asking a group of posting physicians for their opinions. However, I doubt that they have appreciated the answers they have received.
I think there is much more anger out there than they anticipated. And we ARE a representative group, just more vocal.
Sermo Doc 78, I maintain that you are very wrong in asserting between the lines that in 9 months of office, President Obama has killed the desire, stifled the creativity and forced some social agenda on us that has taken away our "opportunity" for a better life. You may deny you are saying that, but I believe that is exactly what you and some of the others are saying. The country has not changed overnight. Just because the current holders of power (read that as Democrats) do not march in lockstep to the tenants of the rightwing radio talk show hosts you apparently listen to, you are whining about having your opportunity for a better life taken away.
"The internet may prove to be valuable as a way of reaching and uniting physicians. Apparently, SOME Senators already see the benefit of asking a group of posting physicians for their opinions. However, I doubt that they have appreciated the answers they have received."
The internet is the opiate of the masses when it comes to Senators asking questions of a group of physicians. Have you gotten much help lately from Sen. Coburn who did this little exercise a couple of weeks ago? Do you suspect that Sen. Cornyn will be much different?
Senator Cornyn - Thank you for requesting our input. I must say that the comment that "the people who wrote [the bill] did not want to take on the trial lawyers" astounds me. My question for you, and all of our elected officials is, do you want health care, or do you want the threat of lawsuits to make it unavailable? That may sound like both an extreme and a rhetorical question, but it is neither. There are areas around the country where OB care is not available at any price due to excessively high malpractice premiums having driven practitioners away, or out of OB practice altogether. I for one considered going into OBGYN, but decided against doing so, in part because I did not want to have to worry as much as they do about being sued. As they say during space missions when things are not going well, "Houston, we have a problem". Without tort reform neither cost control nor even adequate access to care will be possible, even with universal coverage, especially if that "coverage" involves reduced payments to physicians, for example if more people become eligible for Medicaid.
If you look out for lawyers, you will get more lawyers, and more legal actions. If you look out for doctors, you will get more doctors, and more access to health care. No set of "guidelines" will fix our seriously broken system, but if you allow the federal government to dictate (even more than they already do) how we practice medicine, it will become even more difficult for us as physicians to do our jobs.
I believe that most physicians welcome data on comparative effectiveness, treatment guidelines, standards, and all the other "buzz words" of quality research, but only along with one specific caveat - that the data be offered for consideration as opposed to being mandatorily imposed.
Every practicing physician is aware that not all patients "fit the mold." Whether it is a child refractory to usual care for otitis media or a geriatric patient unresponsive to blood pressure medication, not all patients respond to treatments the same way. Imposing standards in such an environment can be disastrous. Thus, standards are a welcome occurrence within the concept of a "good first try", but mandatory standards are viewed negatively because we find that so often the good first try doesn't work, yet mandatory standards restrict our ability to proceed with alternative approaches.
The suspicion most physicians have towards government stems from the historically proven tendency of the government to become rigid in its approach to almost any problem, be it financial regulation, environmental protection or medicine. After an initial flurry of activity, govt tends to settle down to business as usual, while changes in the landscape cause the practitioners of the regulated profession to need alternative approaches. Yet govt remains inflexible until a crisis occurs, at which point there is another flurry of activity, new standards are implemented, and the cycle, over a course of years or decades, repeats itself. Along the way, however, much harm can occur.
Medicine is particularly vulnerable to govt regulation simply because it is such a complex yet dynamic undertaking. It is hopeless to consider that government has the ability to maintain currency throughout the field, when even highly specialized physicians of the most arcane and obtuse specialties find it difficult. Government mandates in medicine are doomed to fail, both in terms of effectiveness and, eventually, compliance.
Government's role in medicine should be to ensure that an equal level of opportunity exists for industry, providers and patients, but government cannot hope to achieve an equality of outcomes in any of those areas, which is the implied goal of mandatory regulation.
Contrary to popular opinion, physicians are not all avaricious louts whose sole concern is to squeeze money from the patients. While those poor examples may exist among us, even they recognize that the way to do well is to do good, and virtually every physician in the country really does have the patient's best interests at heart. Government regulation of specific medical techniques and practices, however, goes against that altruism.
Yet physicians are not totally altruistic. We do indeed fear malpractice, and many of the decisions we make daily are tainted by the desire to avoid the lottery effects of our current malpractice system. Given the extent to which legal advertising implies any negative outcome means a big money payoff, and the demonstrable effects of that mind set, our fears are fully justified, and we find it necessary to protect ourselves despite our altruistic tendencies.
In order for government guidelines to be most effective, they must be 1) voluntary and 2) linked to some sort of malpractice protection - treatment following guidelines should be protected from claims of malpractice. Adopting these principles allow the physician some protection from frivolous lawsuits resulting from standard care, while also allowing us the flexibility we need to exercise our expertise in ways the government is incapable of foreseeing.
See the current (Nov. 4) issue of JAMA (p. 1865) for an example of comparative effectiveness research. They found that expensive, difficult-to-use "N95" masks were no better than surgical masks in preventing nurses from getting influenza. Isn't this sort of research essential to find out where we are wasting money in health care?
"My question for you, and all of our elected officials is, do you want health care, or do you want the threat of lawsuits to make it unavailable? That may sound like both an extreme and a rhetorical question, but it is neither. There are areas around the country where OB care is not available at any price due to excessively high malpractice premiums having driven practitioners away, or out of OB practice altogether."
Mike, with all due respect, the medical profession has been saying this for decades already. Medical care has not dried up and gone away. Sure, no one wants to get sued. Sure premiums are high for many specialties (has anyone ever looked into how much insurance companies charge vs. how much they pay out in claims?). But the "malpractice crisis" is not at some new boiling point now. This is just not the main problem with healthcare at the present.
And the GOP "solution" seems to consist of mainly of a couple of things right now. One is the tort reform you are seeking Mike, and the other is this corny idea of buying insurance across state lines. Does anyone really think that I will suddenly be able to get a great deal on health insurance because I can buy it through a company in Idaho as opposed to having to shop only plans that are available to me currently in Texas where I live? How in the world could these two things result in any kind of meaningful answer to the health care problems facing the U.S.?
Sermo Doc 20, I agree with you on that point. I have said before on this board that I do not believe that Coburn even reads our responses, much less, acts on them. I bet that his staff does though. The same with Cornyn.
The value of the internet here is that doctors can communicate on these issues with each other. Doing it anonymously is also helpful, I believe. In my particular case, my vocality on matters of policy and quality assurance, have caused me to have some enemies in the profession. I am not upset about it, because these are people I would not want as friends, and neither would you.
Nevertheless, it is useful to be able to speak out purposefully on contentious issues instead of burying them and pretending they don't exist, which is what our profession has done historically.
Perhaps Senator Cornyn with some like minded senators could introduce a bill on reforming the legal system as it impacts on the delivery of healthcare and the practice of medicine in this country. It could be included in the overall healthcare reform or it could be passed separately. Either way it should have the desirable effect of bringing the cost down. This kind of legal reform (tort reform) has waited endlessly for someone in the US congress to pick up the cause and get the appropriate legislation through both chambers and on to the President.
Time may be ripe for healthcare reform simultaneous and parallel with the legal reform in an ideal combination.
Senator Cornyn - I would like to share a story with you which I think will help to illustrate why tort reform is so important:
I am a cataract surgeon. The worst complication that can occur following routine cataract surgery is infection, which can lead to blindness. There is very little scientific evidence in support of the various measures we use to reduce the risk of infection following cataract surgery, and in fact that most efficacious measure, based on the evidence which is available, is the also the least expensive - the sterile prep and drape done right before the actual surgery. I mentioned that fact to a drug rep whose company makes one of the expensive antibiotic eye drops we routinely prescribe for patients after cataract surgery, and he immediately pointed out that if I were to stop using it I would be likely to be sued for malpractice if one of my patients were to get an infection following cataract surgery, whether or not there is enough evidence to prove that the drop reduces the risk of infection, simply because most other cataract surgeons use it.
I'm sure you see my point - drug companies love it when doctors practice defensive medicine! Of course their products are not free, so defensive medicine costs money, and malpractice reform is essential to controlling health care costs. Without it we will continue to be "encouraged", no, actually "strong-armed" into doing things we know to be unproven, just because as that drug rep said to me "all of your colleagues are doing it, so it must be the standard of care". Who among us wants to step "out of line" and risk being sued, when the system fails to protect us against ridiculous claims which have no basis in scientific fact?
Again, no guidelines can fix this problem. We need tort reform!
Sermo Doc 52 has it right regarding the FDA's role in approving new medicines. Years ago the FDA was charged with establishing the safety of new medications. Then came the congressional mandate to also establish efficacy. The studies that are now mandated really do not do this in many instances. Head to head comparisons with existing treatments are needed. Or better yet, return the FDA to its form role of just certifying safety. Clinical use will soon sort out effectiveness. Case in point: there was a comparison study a couple of years or so ago of Imitrex (hugely expensive and relatively newer) vs. Midrin (very old -- it was on the market when I was a medical student in the late 1950's -- and very inexpensive) for migraine. There was no significant difference between the two. Midrin is currently beign withdrawn by the FDA because the original studies did not meet current regulations for approval as a new drug. If the manufacturer were to submit the data now required for approval, they would never get there money back without making Midrin just as expemsive as Imitrex.
And Midrin is just one of many older medicines being cancelled by the FDA. The other step badly needed is to absolutely ban advertising of prescription medicines. The drug companies complain that new medicines cost so much because of R&D. Yet many of the companies spend at least as much on advertising as the do on R&D.
More and more laws, in the form of rules, regulations, and policy pronouncements,are made by administrative agents and CZARS. These are outside of the open and transparent requirements of responsible government, and without congressional approval and oversight. This is beyond the principle that legitimate government arises out of the consent of the governed, i.e., no representation of or by the PEOPLE.
The more government regularly operates as a matter of course outside of popular consent, the more we become clients rather than rulers of a vast government, the less we are self-governing, the less we control our own fate, and the less our elected representatives have to say about our political future..
As Alexis de Tocqueville warned in 'Democracy in America', this is the recipe for a benign form of despotism that truly imperils our democratic experiment. Now, the chaos of our economy has presented a new opportunity for the WH to create a grand Socialist system of Govt. to control all aspects of our lives.
I thank you, Sen Corzine, for the opportunity to discuss the topic, but I can't, in good conscience, answer any of the questions because you are talking about something other than what most reasearchers in comparative effectiveness do.
Comparative effectiveness research has, for some reason, attracted the ire of physicians as a tool for rationing. However, it is a limited tool that will give us some data about what drugs work where, and for what types of people - things we don't know now. When I did primary care, it was nice to know that a solo Ace inhibitor wasn't likely to be the best drug for African American patients as a first line drug, but that combining it with a thiazide diuretic would give me the best first line odds of control.
The draconian restriction on theraputics and drugs is unlikely to occurr for the following reason: a) Americans won't put up with it, b) it isnt' an effective way of doing business. Now, if you are doing procedures that turn out to be not better than sham (say, a orthoscopic knee "clean out", or chiropractics), then you have reason to worry that you'll be denied payment by the government. However, it doesn't mean that, just because you sell snake oil that you can't charge cash and stay in business (just go to GNC and see for yourself, snake oil is alive and well); just don't expect the rest of us to foot the bill.
As a sidenote, I do some comparative effectivenss research as part of my work, and do have grants out currently for more. However, most of the work I do is in comparing routes of delivery, methods of delivery of drugs, along with patient outcomes. Our aim is to provide practitioners with information to make informed choices at the bedside with patients - and we write our papers that way. Now, not all of our work is popular (ie if we find a therapy is actually harming patients or a subgroup of patients is the only group that benefits, etc), as we recommend not doing that anymore - or at least changing the way that we deliver that therapy (ie. pediatric lung transplant for CF) or futher study.
I didn't do the survey so I guess I missed the tort reform questions. Indiana's model is the model that should be applied nationwide - a panel of three physicians reviewing the case prior to trial, and the recommendations of that panel are admissable in court... and the panel is required prior to trial. Malpractice costs and costs of care are low in Indiana. If the Republican party was interested in getting anything done on tort reform, they could this year. The Democrats are interested in looking bipartisan, and would be willing to fold in tort reform to a bill if the Rs would vote for it... but it won't happen because no one in Washington wants to look like they compromised on anything. Too bad for America that we've become so rigid and inflexible.
As for protocolized care talking over your life - it will actually make it easier in that standards are published. If you think that a patient won't benefit from (or if they fail) standarard therapy you won't have a beaurocrat hanging over your shoulder...
As a young physician who is frequently at the hospital late with patients in the ICU, I can tell the old geezers complaining about us young folks abandoning patients to stick it where the sun don't shine. I get tired of hearing senior physicians complain about us not working when I'm putting in 100+ and they are doing 60. I'd say I'm sorry but I'm not.
As a academic physician, I welcome your input and interest in this discussion. Unfortunately your survey is a highly biased inprecise instrument with a clear preference for getting the answer you wish. I believe that clinical guidelines, when applied appropriately and thoughtfully, can guide care. They cannot substitute for clinical decision making at the bedside, but they can and should be used for the common presentations that offer the ability to have less variability in care and greater cost efficiency. In Emergency Medicine, there are multiple proven and valid guidelines that are used to decrease radiograph ordering and radiation exposure to patients. There is no reason that the goverment, (as a major payor) should not be involved in the process. The insurance companies clearly are already.
Blatantly biased survey, the results of this survey are meaningless. But they will be used anyway to bolster the positions of those whose opinions they support. I agree with Sermo Doc 86, The republicans also have the ability to propose legislation, and could have done so many times in the past 20 years. Only now that the democrats have tackled this issue do the republicans speak up, mostly to say NO. There is much about the current proposals for health care reform I don't like, but I appreciate that the democrats are trying to address the issue, and instead of trying to be constructive the republican party has abandoned its responsibility to participate in the process
Since the Congress voted not to repeal SGR and CMS has finalized the 21% cut This is moot! Doctors will be bankrupt and in line for TARP or opted out taking cash and ignoring the Government meddling. Can't wait until January when SGR hits the fan.
Sermo Doc 20, likewise, remind me to never be under your anesthesia services...ever. You are the absurd one, with your absurd rhetoric. It is very obvious you portray an agenda, an absurd agenda. Don't wish to debate or discuss anything with you, so don't bother. I rather debate with someone that is in the trenches of medical care, like I am.
Sermo Doc 20 - Good point, I agree that most medical care is not going to dry up and go away in spite of the malpractice issue, which is certainly nothing new as you said. Still, I do believe that there are in fact areas where OB care is not available because the local malpractice "climate" is particularly harsh.
My biggest concern is that the fear of being sued leads many of us to "go with the pack" when making treatment decisions, rather than trusting our own education and experience as well as the peer-reviewed literature to guide us. There is also an awful lot of off-label drug use promotion by drug reps, who sometimes will stoop so low as imply that the standard of care in a given situation is defined not by any scientific evidence, but by what they have been able to convince most doctors to do.
The very existence of the medical profession may not hinge on malpractice reform, but effective cost control certainly does.
I agree with drnopain and Sermo Doc 2, but surgonc is probably most realistic. CER is here, and here to stay. It has potential for improving care, but it must be allowed to evolve within the framework of the medical community. As database registries become the norm and massive amounts of evidence based care data is amassed, I can see a time when evidence based care guidelines will become a valuable tool. I can absolutley guarantee its failure as a valuable tool if it is used by the governemnt to control costs. The value can only be realized if used in conjunction with research based through clinics, institutions and medical researchers to actually improve care. The bottom line is:
The AMA does NOT represent me, nor the majority of Physicians in this country. They are a self-serving organization whose purpose has become to make money through their exclusive monopolies on the use of billing codes and RBRVS.
The government health care reform, as proposed, will do to medicine what the government's involvement has done with the post office, social security, Medicare, Medicaid, public education, etc... I cannot think of one thing the government has done better than the private sector, and plenty of situations where it has driven them into the ground. Why should I think they can improve on health care financing?
If you want to fix the economy, leave health care alone, loosen up red tape and taxes on small businesses (I run one, and it gets more difficult and expensive every year), and support all, I mean ALL measures to investigate, audit, and eventually SHUT DOWN the FEDERAL RESERVE BANK! This, Dear Senator, is the meat of the issues facing our economy. They are a private group of wealthy bakers that run Wall Street, our Department of Treasury, and are in charge of monetary policy and money supply, and through their artificial manipulations of money supply, have mangaged to STEAL America blind! They profit, repeatedly, from our losses.
End the Fed and many, many of our problems will resolve, through allowing the free market to control our economy. Remove artificially imposed barriers on the free market, and give our money some real value by, once again, limiting the supply and backing it with hard assetts. If it doesn't occur, we are all screwed.
James Landers, MD
"The AMA has officially endorsed the Democratic health care reform plan."
That settles it. The AMA is now officially the enemy of real practicing doctors in this country. No organization that truly represents physicians can endorse ANY reform legislation that does not contain MEANINGFUL tort reform, period! That IS and will continue to be, the acid test.
"Sermo Doc 1 Rheumatology Posted Nov 04, 2009 at 1:43 PM
Cornyn the Barbarian! Thanks for gracing Sermo with your presence.
Can your survey be any more biased and leading in its questioning?!?
All you need now is a link to donate money to the GOP after instilling the fear of government takeover into the trembling right wing docs on Sermo. "
Please. At least the GOP is representing physician interests. If you ever got your head out of Obama's posterior, you'd realize that he doesn't give two sh*ts about physicians as a profession, and is more interested in scoring political points than actually improving healthcare in this country. He'd much rather protect the trial bar.
Expanding an underfunded/nonfunded entitlement without substantial increases in revenue or decreases in costs results in no deficits in which alternate universe?
1. All you have to do is look at the UK experience, where CER is established. The health economist Alan Maynard, writing in the J. Roy.Soc. Med, this summer, called it just what it is,"a rationing mechanism". Private insurers in the US have been quietly using it for some time.
2. Tort reform is a no-brainer. PriceWaterhouseCoopers (2008) estimated it at 10% of total HC costs, i.e. 200 billion. You could cover all the poor with this amount of money.
Sermo Doc 20 said "Hey, how about the far rightwing radical in upstate NY who Palin, Beck and her ilk tried to foist on the voters. They even forced the mainstream Repub. out of the race."
Yea that's the "mainstream" republican who endorsed the democrat - I thought you were supposed to be a physician to comment here. This quote comes straight from David Axelrod's talking points. Calling that nerdy accountant who needs to see one of the Ophthalmologists posting on this thread immediately for strabismus surgery a "far rightwing radical" is hilarious.
In the past Comparative Effectiveness Research (CER) was the province of a small cadre of scientists and policy analysts. CER is not new: the Agency for Health Care Research and Quality (AHRQ) has funded some 28 centers which have produced a wealth of evidence-based data on the cost effectiveness and efficacy of drugs, medical devices and procedures used in the treatment of various disease states. On 17 February 2009 President Obama signed the American Recovery and Reinvestment Act of 2009, which allocated $1.1 bn for CER studies that directly compare the risks and benefits of different treatments for a particular condition and are essential for improving care and controlling escalating costs. [1] The act also mandated the Institute of Medicine to recommend "national priorities for comparative effectiveness research." [2, 3] It established a Federal Coordinating Council for Comparative Effectiveness Research whose task it is to recommend and to coordinate such research but will not be able to establish clinical guidelines or to "mandate coverage, reimbursement, or other policies for any public or private payer." [4]
CER is the mode to identify the method of treatment which is most effective for an individual patient under specific circumstances. It is anticipated that CER will yield greater value for the US healthcare system and better patient outcomes. [5, 6] The best definition is seen in the IOM brief: "CER is the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care. The purpose of CER is to assist consumers, clinicians, purchasers, and policy makers to make informed decisions that will improve health care at both the individual and population levels."
It is intuitive that such methodology is necessary to improve care and to control cost for all patients. Unfortunately, this has generated a coterie of interest groups asserting, despite evidence to the contrary, that CER will have a dampening effect on personalized medicine. [7, 8] Other nescient opponents—especially certain Republicans and their ilk—has expressed concerns, totally without any substantiation, that CER findings could lead to rationing and government intrusion into the doctor-patient relationship. [9]
CER enables both healthcare providers and consumers to make better informed choices, thereby, improving the quality of healthcare services and reducing healthcare costs. The aspiration to provide better and more cost-effective healthcare through the application of CER is shared by the US Cochrane Center and by enlightened stakeholders throughout this country. The question to be answered is will CER guide clinicians into adding the knowledge base to and making appropriate changes in their daily practice of medicine. [10, 11, 12, 13, 14, 15]
References
1. The American Recovery and Reinvestment Act of 2009 (accessed at
(http://thomas.loc.gov)
2. Institute of Medicine, "Initial National Priorities For Comparative Effectiveness
Research," Report Brief, June 2009
4. Conway, PH, et al., "Comparative-Effectiveness Research—Implications of the
Federal Coordinating Council's Report," NEJM; Online First, 30 June 2009:
10.1056/nejmp0905631
5. Kuehn, BM, "Institute of Medicine Outlines Priorities for Comparative Effectiveness
Research," JAMA 2009; 302:936-7
6. CBO, "Research on the Comparative Effectiveness of Medical Treatments: Issues
and Options for an Expanded Federal Role," December 2007
Sermo Doc 1, add something constructive. I firmly believe there is no right or left wing .Whichever politician serve the needs and interest of the medical community should be promoted.
Our bowl of rice hangs in the balance. Leave alone the dollars and cents issue. What is right for the patient will become secondary.
The "left wing" stance ala Pelosi / Reid / Obama et.al. will lead to a cast system of haves and have nots. Free market capitalism where the monopolistic insurance giants lose their anti trust protection is the one feature I agree on within their current 2000 page proposal. If the annual premiums drop precipitously, the whole system would benefit.
Senator Cornyn, As one of your constituents I again urge you to consider the logic that individual choice is fundamental to competition and real change. Reshuffling the deck of insurance, employer, and government interests alone does not make things inherently different. I find it completely illogical to say that we must save/increase Medicare (a government [poorly] run program) from one side of the mouth, while from the other saying NO to a government run program. Have we learned nothing from Madoff? Our veterans from the greatest generation (and now the boomers) have been thrown to the VHA (not a shining example of government run healthcare) or stuck with TriCare only to be kicked out to Medicare when they reach age 65 years. We know this will happen. Finally, health care is not a right, nor should it be mandated by law to carry. In fact, health "insurance" is largely only a pre-payment agreement, most of the money from which gains employers tax breaks and is not used by patients (does not accrue or roll over like HSAs) when young and relatively healthy -- too much insurance! Divorce health care decisions from peoples' employers, give us tax breaks to use that money the way we see fit, and stand up for us physicians when the President tries to demonize us in front of the American people! Thanks for your support
Sermo Doc 67, I am a physician and can post here just fine. I have no connection to Axelrod, thank you very much. And the nerdy accountant in the upstate NY race was a rightwinger handpicked by Palin, Beck, Limbaugh, etc. If that's the direction the GOP is headed, then they might as well jump into the harbor with the teabags.
If there was no tea party in Colonial Boston and no Revolution, we'd all be working for the UK National Health System and still drinking their tea...or is it KOOLAID now???
By the way, in 1776 there was no GOP, which was the party of Lincoln (a big favorite of Obama).
Sure, fund the research, but don't abuse using the info. There are exceptions to every rule, and studies often have conflicting findings. All things in moderation. The questions in the right column are "loaded" and do not get at the heart of the issue of what is best for patients.
Thankyou for your request for input directly from the physician community. Although there are many viewpoints here, many many of us are deeply concerned about the direction that the healthcare reform bills in the House and Senate will take us. The AMA's endorsement of H.R. 3962 just does not represent American physicians at large with their membership at less than 20% and falling.
Healthcare is complex and there are many issues in addition to the two you mention:
Medical Liability Reform - This is a must. The Texas experience illustrates the increased physican supply that resulted after your states reforms were put into place. Amazingly Pelosi's bill not only provides NO medical tort reform but would punish states like Texas that do. THIS IS EXACTLY THE WRONG THING TO DO. Out of control malpractice insurance drive physicians out of practice with ruinous effects on access to basic services - especially obstetrics. Add the expense of Defensive medicine and the status quo is untenable.
Competitive Effectiveness Research - certainly has a role in healthcare - but should NOT be an arm of the Federal Government where it has the potential to be used for rationing and denial of care - even when the treatments have been proven safe and effective. Please don't let "Health Benefits Advisory Commission" be allowed to cut off effective treatments to our citizens like the U.K.'s NHS has done with treatments like Herceptin for Breast Cancer.
The private medical sector has provided leadership in application of safe and effective treatments. The Anesthesia Patient Safety Foundation is a prime example of this.
We need more Competitive Effectiveness Data and Research, but the government should not be the entity entrusted with applying this information to medical decisions. That should be left to physicians and patients. Pay for performance measure could be used to carefully encourage appropriate treatements, BUT outcomes and treatments need to be chosen VERY CAREFULLY and only applied when there is OVERWHELMING evidence for or against certain treatments. This process should never be rushed or politicized. Even though pay for performance efforts have just started they are already misguided in many cases - for example some of the "never events" recently imposed by the HHS. These are events that are to "never happen" and thus are not re-imbursable. Some make sense like and some absolutely don't.
As anesthesiologists we are greatly concerned about government healthcare:
online.wsj.com
Unbelievably, in the worst recession since the great depression, the HR 3962 places new onerous tax burdens on employers, medical device makers, and the "wealthy". Can we really afford this bill? I think not. We have a deficit of $3 Trillion over the first 2 years of this Democratic President's Administration! Yet we celebrate this bill shaving a MEASLY $34 billion off the deficit in 10 years. Just last week the estimate was $88 billion in savings. Given the history of massive cost underestimates in government's involvement in healthcare, I doubt any of these savings will ever materialize....EVER!
The bill states that the public option will never receive federal funds in case of insolvency. This is disingenuous at best given the recent history of our bailout nation including Fannie Mae and Freddie Mac that have added trillions in unrecognized liabilities to our nation's balance sheet. A bankrupt public option will most certainly fall under the auspices of "too big to fail" and will most certainly receive public funds if this eventuality is ever realized.
Instead of this massive expansion of government entitlements and potential liabilities we should be embracing free market reforms, encouraging individual responsibility, encouraging increased supply of qualified physician and healthcare provider labor, strengthening the healthcare safety net, and finally rewarding efficiency, productivity and most importantly continued innovation - not stifling it with higher taxes and suffocating regulation.
Healthcare reform is clearly needed, but more than anything American needs health insurance reform, not a massive new government entitlement program.
Increase competition by dropping the anti-trust protections that these companies enjoy and allow insurance to be bought and sold over state lines. Neither of these provisions is in the current bill. Require all insurance companies to accept patients regardless of pre-existing conditions. No lifetime cap on benefits should exist. We have all seen relatives and friends that are denied coverage when they need it most. WE NEED TO CHANGE THIS.
Insurance should be uncoupled from the workplace and individuals should not be penalized just because they don't get their policies from their employers; an individual mandate to buy insurance with vouchers for the poor to buy their own policies in the private market should be adopted - much like food stamps allow recipients to shop at the markets of their choice. Government should rightly provide a safety net by helping those who are indigent and underserved. We need to strengthen this safety net but a new massive government entitlement will only make healthcare worse - not better.
An individual mandate should be in place with penalties high enough to avoid "gaming the system" like that which was seen with Maine's failing Dirigo plan and is being seen in Massachusetts now. Policies should be high deductible with HSA-like accounts that allow consumers some "skin in the game". HSA contributions should be tax-deductible and if not fully spent applied to higher educational expenses for family members or eventually become a supplemental retirement account (like a 529 or a Roth IRA). This provides both required health savings and an incentive to reduce utilization. I don't see anything like this in HR 3962
Patients must be responsible for their health. If basic healthcare is a right then it is also a responsibility. What basic risk factors can be modified should be modified. After reasonable "grace periods", insurance companies should be able to increase premiums when improvements in risk factors deemed modifiable by a patient's physician are not attained. This is not unlike auto insurance and provides a mechanism to incent lower utilization through decreased risk. This need not be complicated or intrusive. Simple efforts in the areas of smoking, cardiovascular health, and obesity/diabetes prevention are already yielding tangible benefits in private companies. Individual choice remains intact and allows individuals to choose a higher-risk lifestyle if they so choose; lifestyle choices with risks and costs that individuals alone are burdened with and not society as a whole as the system now allows.
Market based solutions are working now within private companies with great success:
Electronic medical records should be implemented with government mandated deadlines for implementation and private market solutions. Providers that generate health data should be required to electronically share this data through secure systems much like the credit bureaus share financial data. This is much overdue and will streamline patient care, improve safety, and provide modest overall savings. Jiffy Lube tracks oil changes better than patients' echocardiogram data is tracked and shared between providers.
Enacting HR 3962, physician supply will dwindle in the form of quality hospitals and providers. Wait times will increase. Healthcare will become an electoral issue every political cycle as it is with our socialized allies Canada, Europe, and Japan. Quality will suffer. People will suffer.
Today, graduating physicians are burdened by hundreds of thousands of dollars debt from their medical training and struggle to pay this debt every month. The bill as currently written will eventually result in government price controls and decreased physician incomes. This along with unchecked medical education debt will severely decrease physician supply just when the baby boomer demographics demand more medical care than ever. This will inevitably result in decreased quality and increased delays for the care that our citizens need. Any healthcare reform need to redress these issues. But amazingly there are no provisions in current bills that addresses maintaining adequate physician supply.
Our Forefathers designed a system of government that has worked for generations because of their insight and wisdom; designing the perfect system of checks and balances, individual rights, and the balancing the Federal and State systems. It was and continues to be a miracle. It simply works. Our political system was unique, designed in the midst of failed, unjust, and cruel regimes the world over. It was the innovativeness, the uniqueness, and the justice of the system that has made it the model for the rest of the world.
Just as America led the way in creating an unparalleled political system, it is time that we do so again by creating a truly unique, innovative, and fair healthcare system that is American in nature and will become the model the world will follow and not simply a copy-cat system of European-style government-run healthcare.
Healthcare is too important, too personal to relegate to a "government program" - our citizens deserve better than the rationing of the socialized systems of our European and Canadian allies which will be the ultimate result of a public option. An option that will eventually crush private competition, imploding into government-run single-payer system that mandates who can have what care and for what price. We are Americans - we can do better - we expect better and we deserve better.
Senator Cornyn,
I disagree with many of the above postings with regard to comparative effectiveness research. WE NEED IT. There is tremendous waste in medicine, both from defensive medicine and from overuse of treatments of questionable benefit, often with large price tags. As a taxpayer and health insurance purchaser, I hate that my taxes and premiums are wasted in such a fashion. Malpractice reform + increased comparative effectiveness reseach = reduced costs and probably better care. Sermo Doc 97 laid out the history and case for comparative effectiveness research well. The losers would be pharmaceutical and device companies who spend more on marketing than R & D.
Mr. John Cornyn:
I know that we docs could not possibly be as cleaver as you.
But, dang, as dumb as I am, I know that the question you ask is talking down to us.
You are a work of art, just like Damien Hirst's Hundred Years, a large glass case containing maggots and flies feeding off a rotting cow's head.
And Sermo, wow, you are clearly interested in our input(as long as you can slant it your way!!)
Some of us care about U.S. medicine and our patients.
Did anyone notice that today, at the teabag convention in DC, a leading GOP representative who shall go nameless (John Boehner, oops) standing with Rep. Michele Bachmann and others in front of the teabag audience, recited words from the Declaration of Independence as he stood there waving his copy of the U.S. Constitution and stating how important the "Constitution" is to America. I tell you what, if this man doesn't know the Constitution from the Declaration how can we expect him to know healthcare reform from the status quo. Oh, right, he wants to keep the status quo anyway so it doesn't matter.
P.S. M. Bachmann did not appear to notice that her man Boehner was reciting the wrong lines.
Thank you , Senator. Defensive medicine is real and costly. Fear of litigation is high and growing given the ever mounting "jackpot" awards for pain and suffering. Patients have numerous imaging and laboratory tests performed just for fear of missing a rare diagnosis.
Tort reform is urgently needed. most lawsuits are frivolous. doctors always lose even if they win when you assess the emotional and financial toll of the lawsuits. we need to punish lawyers who take on frivolous suits, use screening experts to deem whether cases are meritorious and perhaps have the loser pay the legal fees.
comparative effectiveness is not useful. clinical problems as they pertain to an individual are complex and do not lend themselves to a simple forumla. this task should be undertaken by medical societies who understand it better.
I am not answering the survey because I do not feel the given choices adequately address the true issue. Comparative effectiveness means absolutely nothing to me when not giving the gold-standard each and every time leaves me at risk of a huge, practice destroying lawsuit. I don't care if the data says one treatment is more cost effective than another and that there is only a minor increased benefit of the more expensive treatment when I have to spend so much time and resources covering my ass in charts to avoid getting taken to court if I go with the cheaper option and there is any sort of adverse outcome at all! I think we all need to agree that there can be no effective overhaul of the health system in any direction unless national tort reform and physician protection from lawsuits is included! If a plan includes any mention of comparative effectiveness then it must also include protection for a provider when they elect to go with the data. That said, I feel if there is to be any sort of tax supported option - and I feel there should be - then there is a requirement of some type of rationing. There must be or it will be financially impossible. Does this mean there needs to be "death panels"? Does this mean someone has to stand up and say which patients are more beneficial to society and deserve to be treated? No. But it does say there needs to be a way to avoid frivolous care - like the multiple Medicaid recipients who go to the ER for their colds because it's "free" and then they can get a prescription for ibuprofen and robitussin and then it will be "free" as well - as well provide good, evidence based, patient centered care when needed rather than getting a CT for every headache due to the fear of the one in a million brain tumor that might be missed and cost someone their career. I feel all publicly insured patients - Medicare, Medicaid, and any new program that comes down the pike - should be treated first in a residency setting. I believe residencies should be our nationwide "free clinic". They are already funded extensively under the Medicare budget. Most are in non-profit institutions. It will provide exposure for all our up and coming physicians to the tribulations of other Americans who are not so fortunate to be able to go to med school. It will also provide access to care for that population when so many private physicians are turning them away. If there aren't enough available appointment slots in the residencies, then expand them. Plus make it an option for graduates to continue working there after residency to shoulder part of the load in exchange for loan repayment. I could ramble on forever and have many more Ideas, but I doubt many of you have read this far already, and certainly not our esteemed surveyor or his staff, so I will end here. Respectfully, Jim Yerger, Family Physician
Comparative Effectiveness Research....sounds like a great idea. I assume this means looking at which approaches are most effective to solve the problem at hand and then restricting payment for those that don't follow the appropriate guidelines. A wonderful money-saving idea. So let's see: attorneys who take on malpractice suits that are flagrant so that they can get money from the malpractice carriers and doctors but don't follow the guideline of filing appropriate suits for actual medical malpractice should not get paid. Right? Oh, and politicians who bring bills to the floor that are earmarks not in the appropriate interest of their constituents or the Country in general should not be kept in office. Right? But then....we don't want to interfere or mandate the practices of any other professionals except Doctors, since only the Doctors are in it for themselves and have to be corralled and controlled. What nonsense!!!
Too much political rhetoric from doctors with little perception it appears, about the financial mess we are in...and how we got here. Those of you who feel the Repubs would be better for medicine than the Dems are smoking bad weed... They passed the part D Medicare change, no funding for it of course, further driving us in debt. They were more concerned with a brain dead vegetable in Florida than any kind of national tort protection for us or really anyone.
POTUS does NOT care about doctors... or really about maintaining the highest quality of medicine possible. He cares about insuring/providing insurance for the 10's of millions of uninsured, and providing some sort of mechanism so that if you become ill, you will not be driven into bankruptcy.... The neo-cons on this site are all whining about him being evil etc.. nonsense... his concerns are with others,, most of whom far less fortunate than most of us! Get over it.
If government got out of health care, we would be almost immediately back to the 1950's where one illness bankrupted an entire family. 50 years ago, we did not have that many MRI's, CT-guided biopsies and broad spectrum antibiotics and chemo... You LUDDITES who keep insisting to return to the "good" old days with no dialysis, no CABG's or stents etcs.. are so blindly wrong..it is nauseating.
As long as the government shields people from the costs of their care, there will be an UNENDING stream of demanding patients insisting that "everything be done for dear old dad." Rationing through best practices policies is the only way to control cost in that scenario... Otherwise, if you make people pay for part of their care,,, no more chemo, PET's, hip replacements for those older than 65 etc...
The poll above is insultingly Right Wing Fascist Fox crap, and I did not answer it's pseudo-questions.
The health care changes will not be as drastic as so many of you fear right away as many docs are employed and there situation will not change... and many others have families, kids in school and cannot just drop medicine...
CER is obligatory if this country is going to control costs... but its results should be guidelines and should help us defend ourselves in case of a lawsuit.
Haystack, Macleod and Sermo Doc 83 all have some excellent cogent comments.
That the AMA can support health care reform without any national attempts at tort control should show every American Physician where we stand in their eyes..
The ACP, AAP, ACS and AAFP which together represent a whole lot of docs, have not said anything yet... I wonder..
Also, we need to re-focus this forum to be an exchange of ideas... The calls by some for revolution etc... keep it to yourself.. We all know of worst case scenarios... we are not even in the same galaxy as those kind of extreme options. I fear that talking mouths like Sen Cornyn don't really give a c#$$@ about us and are just politicking.. I really doubt anyone in power reads any of this... If we don't form a union or have some meaningful political power, we are all really just wasting our time on issues like this... Better to go back to interesting medical cases ...
i know system in EU so I answered the second question it will be very effective. if nothing is indicated so nothing will be ordered so a lot of money will be saved
You are right about the excessive sales of glasses and the poor training of many optometrists.
I believe that medicare part B should pay ONLY MD's and DO's and probably oral surgeons and podiatrists.... Not optometrists, and not NP's and certainly not chiropractors!
On the other hand, I object with being lumped in with optometrists in the way you suggest.
I am so busy taking care of MediCal patients who need medical and surgical eye care that I simply can't take my time to provide glasses and contact lens exams. There are 2X more optometrists in this country and they SHOULD be providing this service.
In California, I can not allow my technicians, opticians (if I had one) to perform refractions...its against the law. That is so stupid I can't even describe it...so I would have to take my time to do that exam, vs spend the time taking care of diabetic retinopathy, cataracts, etc....
I do NOT participate in kickback arrangements with optometrists either (and thus lose a lot of business) but I sleep well at night about that issue.
You ARE so correct about the money wasted by people who are sold way too many glasses.....but this is not part of medicare or mediCal anymore (neither are optometry exams part of CA Medicaid anymore...which is correct as far as I can determine)...
I ask my pts if they see well with their current glasses. If they say YES and I can verify this on exam...why would they need new glasses??? Unless they are damaged or the pt is financially able and desires a new style...I tell them to save the money.
Sermo Doc 111, Please go back and reread my post. I was quoting another poster. I was not the one making the points about too many eyeglasses being sold. This is small potatoes in the overall scheme.
I was making the points about ophthalmologists being too busy to want to fool with routine eye exams and refractions. I was making the point that this is why so many patients are turning to optometrists who are providing a much needed service. I was also making the point that these patients will likely stay with their optometrists for medical eye care, for better or for worse, simply because they have established a relationship with them due to the fact that the overly busy ophthalmologists could not make time for them in the beginning to refract them.
I do not think the senator is reading any of this. If he did, I am confident we would have heard some discussion from his end. I have not heard of a silently agreeing politician (the only silent ones are the dead ones).
This kind of enquiry is quite insulting to our intelligence and a waste of our time. Many of my colleagues have put up very elegant and cerebral answers, not just repartees. I also see some of the posts have references. The least you could do was prove that you are serious about this and join the discussion.
This is a worrying that senators are allowed to put up posts which serve only to inflame. Let us not have any more threads from them UNLESS they particiapate in the thread.
I know that Sermo is predominantly conservative - but I must express dissent.
I am strongly in favor of a socialized health care system in America. We absolutely need it. I support a hybrid system similar to Italy, where there are both privately owned and public hospitals, but where the government subsidizes or completely pays for both sides. Such a system ensures competetiveness between private and public sides, and generally ensures good care on both sides.
I hate that we scorn the word "rationing", like it is something bad. We have a limited amount of money to spend on health care, and it must be apportioned in some way. Each individual patient wants everything possible done to maximize their potential outcome, and each doctor wants to do everything for their patient. Unfortunately, those two truths add up to unlimited cost health care. There must be a third party of unbiased experts who come up with some reasonable limits on what will be provided. Insurance companies already do this, all the time. They use Anthem and Milliman guidelines to decide what is and is not "medically necessary", and often don't pay for something that is out of guideline, even on appeal. So rationing is nothing new. The country just doesn't realize it.
Tort reform is an absolute necessity. There is no question that health care is made much more expensive by defensive medicine. Just today I ordered a breast ultrasound on young woman that I am 99.9% sure has no problem, just to quell her concern over a benign finding in her breast. I wasn't really thinking about liability when I ordered it, but liability has created a general mentality that we must search to all ends to find any disease, no matter how slight the possibility. The system has lost sight of the fact that doctors are there to improve health and to the best of our ability detect and treat disease. We are not the causes of the disease. There is something fundamentally wrong with the idea that we are liable for the death of a patient from a natural process, just because in some iteration of reality we might have caught it if we had made a different choice. We only live once; we don't get a chance to take it back if we make the wrong choice. Who holds anyone to a standard of always making the right choice? Its ridiculous. Its like we are responsible for every alternate reality that emanates from this moment, yet we only get to live one of them. It more than double jeopardy, its like jeopardy ad-infinitum.
I hope you get a chance to read this, as it differs from the majority of comments you will see above.
Senator-
1. government needs to be a referee not a player in health care. i agree for need to imporve balance of power between health insurance companies who makes all the rules and decisions now and patients and docs. level the playing field. End anti trust exemptions- break up the big insurers Well point , united heathcare into smaller competitors- just like Standard oil and Bell in the past. Make them compete on service and price . Allow inusrance to be sold across state lines. Allow doctors,pateints and employers to cllectively bargain on price and fees Have standard efficient billing and payment rules for all payers - based on AMA CPT guidelines currently in place . Medical necessity to be determined by an Independent ( not government appointed ) panel - see #2 below
2. Have independent multidisciplanary panels (IMDP's)
of all the stakeholders- funded by government and insurance profits to determine "comparitive effectiveness" and set up "Best practice guidelines".Many of the guidelines already exist for many clinical problems as noted in the Medical Literature. ie North American Spine Society guidleines These guidelines will not determine payment if reasonable alternatives are available or it data is lacking . Only recommendations with overwhelming Grade A evidence with no reasonable alternatives will be allowed to determine payment ( i.e. appendectomy for ruptured appednix, surgery for broken hip ) The majority of the panelist's should be physicians with subcommittees for each specialty- the doctors on the panel will be selected by each specialty organization like American College of Surgeons etc. . Patient advocates , Insurance representatives, Government reps, pharmacutical and med device reps , Epidemiologists and Economists all have a seat on the panel but doctors should have the majority of votes. Doctors are in the best position to know what is best for patients. These panels dictate the rules to all insurance payers. If reasonable (not excessive) documentation is appropriate, then the treatment is paid promptly ,electronically within 30 days -period. this will simply the billing /collection process and eventually decrease doctors overhead and allow us to reduce fees and costs
3. Med malpractice reform is essential!!!!- having visited hosptial and doctors in Germany and speaking with physicianswhove trained or work in Canada, England . France, the biggest difference between our health systems and theirs is the lack of defensive medicine and lawsuits. their charts are smaller, doctors and nurses spend less time documenting care and more time providing it!!!. - We need a
"Loser pays" system where plaintiffs attorneys have to risk compensating wrongly accused doctors to force them to make sure they take on only cases with merit. Merit panels made up of physicians in the same specialty as the accused would determine which cases deserve payment and streamline the process. this is done in Germany Most patients with legitimate injuries due to malpractice are offered immediate settlement which reduces costs for all. it is the greedy trial lawyers (both plaintiff and defense) plus expert witnesses and transcribers etc who benefit most from the current system
'thank you sir for listening
william barrick md
<eyeroll> wow, could those survey questions have been more biased? Comparative effectiveness information doesn't have to go hand in hand with "one size fits all" dear Senator. It will go a long way in reducing the amount spent on Z-packs for bronchitis though.
Chronic disease makes comparative disease research reduce to meta-analysis of clinical trials. There is no way to garner the data easily.
For example, one doctor may have lots of hospital admits for people with a particiular problem because he is ineffective at controlling the problem, resulting in hospitalization, while another doctor may have a large practice of these types of patients, and others send them to him because of his skill. In this case, the skilled guy may get so many trainwrecks he looks like the bad one.
Doing this type of research to a reasonable standard of certainty can be very expensive. Then MDs become liable for knowing what this standards or research was. Finally, the bureacracy will then enforce that this is the only way to manage the patient even when common sense says you should do something difference.
The best example of the problems of this research is the current pharmaceutical system which requires a certain diagnostic code for approval of a certain pharmaceutical. This essentially results in people who obviously would benefit from a certain drug, dying or suffering because the payor decides that its not the write diagnosis and the drug is "not medically necessary."
Comparative effectiveness research certainly could decide when surgery is appropriate, although with same caveats.
We already have these types of systems implemented and they do not work well.
Improvements in quality of care and reduction of costs of care are being achieved through physician-led innovative ways of delivering care. This won't occur by governmental fiat
Senator: I just finished a section of the FP Boards. It is called a Self Assessment Module and can be done as a group exercise with other FPs. We reviewed th evidence for a number of cardiology interventions. There are some interventions (meds, imaging, procedures) which have little evidence that they actually improve lives. I WANT that data in my hands so I have resources to explain to someone why a particular med or xray or procedure isn't in their best interest. Of course those companies which market the med or the CT scanner or the new device will fight this. I hope your motivation for the question is not triggered by a lobbyist or large contributor.
Senator.. Please recognize that President Johnson LIED to CONGRESS and decreased the COpay and Premium for Medicare to get it passed in 1965.. The Head of the Insurance COMMISSION (five member) President of Lincoln National Life, Walter O Menge tried to not let that happen... but President Johnson THREATENED that he would run the Insurance co out of business if they let COngress know the truth.. Johnson also called heads of major Insurance Co and threatened them that they must STOP providing Insurance for People OVER age 65 or be run OUT OF BUSINESS. So, in 1965, with no act OF CONGRESS, Americans over age 65 were DENIED the ability to stay in PRIVATE INSURANCE!! by a lying "PRESIDENT"
also in 1965 it was predicted that Medicare would run out of money in 25 years.. and in 1990 it DID... WE DOCS were accused of causing the problem and Hi technology altho in TRUTH we had remarkably DECREASED MEDICAL COSTS in ASTHMA care and COPD care by cutting out major hospitalizations.. I trained at one of the Premier Respiratory Hospitals.. and the AUDACITY of a LYING GOVERNMENT to BLAME US for WHAT WAS clearly THE FAULT OF THE Corrupt President and party IS A PROBLEM.. YOU CAN NOT LET THEM CONT TO BLAME US! the Democrats have repeatedly CAUSED problems and then BLAME everyone else... just as in the HOUSING MESS... MY Husband was forced to sit and listen to ATTORNEY G Janet RENO and SEC TREAS of P. CLINTON force the banks to GIVE LOANS to hi risk people who NEVER paid any of their bills on time >>"OR BE LABELED RACIST!! "
even NOW, HOW many first time home owners have a clue about the massive property TAX escalation everywhere........... and so this will just repeat the disaster!
Republicans NEED TO STAND UP TO THE SICK DEMS AND FIGHT FIRE WITH FIRE! You can maintain standards and still fight for a REAL America! that will become again "THE HOME OF the FREE and the BRAVE!":
My understanding is that Sermo charges a fairly hefty fee for nonmember entities to ask questions of Sermo physicians.
Just curious: Does Cornyn get a free ride because he's a member of Congress?
If so, does that mean that Sermo is now an open forum for any politician who wants to make a stump speech in the guise of "polling the physician community"?
If not, then who is paying the bill? Taxpayer dollars? Cornyn himself? His re-election fund? Political action committee?
Has anyone wondered about this? Feel free to offer some transparency here, Dr. Palestrant and Sen Cornyn...
In "The Jones Plan: a Reality-Based Approach to Healthcare Reform (http://jonesplan.blogspot.com) I recommend an "American Health Quality and Education System," or AHQES (similar to the system proposed by Dr. Guy Clifton [11]). The AHQES would be a federally funded, non-partisan agency with the mission to: a. Systematically evaluate and publish the effectiveness and risks of all treatments and diagnostic tests. b. Systematically evaluate and publish quality measures for all healthcare providers (doctors, hospitals, etc.) c. Systematically develop and publish standard educational materials to (a) educate patients on the various diseases, tests and treatments; and (b) to educate patients on the meaning of the published provider quality metrics. With the information provided by AHQES, consumers would be empowered in their proper role as comparison shoppers for medical goods and services. And doctors would be empowered in their quest to select only the most effective and least dangerous tests and treatments for every patient.
Senator
Thanks for your interest in real health care reform and for what you are doing.
Tort reform is absolutely essential to any meaningful reform and is long overdue
i agree with Sermo Doc 114 but you don't have to have a socialized system--just one where access to health care is provided for those who are unable to afford it (children, the unemployed, the poor). there is a reason why our infant mortality ranking is around 37 in the world (and its not because we full court press the premies)--its because of all the wealthy nations everyone else has access and so there are less premies per capita.
i would like the senator to explain why this wealthy nation cannot do what other wealthy nations do, and that is provide at min, basic health care to its citizens and at the same time doesn't force people into bankruptcy in order to pay for life-saving treatment.
Comparative research equals more government spending.
Almost every primary care organization and every medical and surgical specialty society have practice guidelines for almost every diagnosis we see. Many even have "appropriateness criteria" to help practice evidenced based medicine. Senator Cornyn should support the concept of letting real (community & academic) doctors lead this important charge for our patients. Physicians are extremely competitive and we do want to prove the quality of care we give. We don't need to duplicate what we already do on a daily basis. Let our professional societies provide the mechanism to prove our quality of care (NCQA, etc).
P.S. After the CMS rules go into effect and the additional 21.5% cut in 2010 there won't be many doctors able or willing to provide highr quality care to patients. If protesters in Iran can orgainize to march against an "election", Someone in our leadership needs to organize a protest to let congress and the rest of America know that cutting reimbursement to physicians is a deadly serious matter. We all have to stand together.
Three things to discuss but first a disclaimer, I practice outside Philadelphia.
TORT REFORM: True tort reform would decrease the size of huge settlements but would also decrease other negative effects of the system: Merely being sued negatively impacts a doctor's practice, even if we don't count mental angush. The amount of time spent in depositions, corespondance etc. can cut down on time to get some work done. The remote effects of a settlement or case decided against a doctor
have implications regarding credentialing, staff priviliges... The upshot of this is that most specialists will order a test if there is a 1:10,000 chance that the illness is present. There is no personal impact of ordering extra testing, but major impact of missing ANYTHING. No doctor is willing to jepordize his ability to keep up mortgage payments even on a 1:10,000 odds, if there is no downside to ordering the test.
SECOND: A major cause of our healtcare crisis is that our system covers, even encourages, care that no other country even considers. I'm thinking about all the ICU care and end of life care that keeps poor old granny alive, even though she barely recognizes her family. I've had to put these people on ventilators, at family insistance,
even though all I really did was burn up dollars and postpone the funeral.
THIRD: Even though I see many problems with the healthcare system, it is easier to see issues with the one sided 'survey' we were asked to take. All the members of this group do not agree with any of the answers to the survey questions.
I WOULD LIKE TO CALL ON SERMO TO FORCE THE SURVEYS TO BE MORE EVEN HANDED RATHER THAN JUST ALLOWING CHOICES ALL BASES ON THE SURVEYORS POSITION. These politicians need to see who does not agree with them and SERMO needs to develop a reputation as apolitical and even-handed.
Sermo Doc 120, I totally agree with you for raising the question of who pays the bill for politicians like Sen. Cornyn to post questions here? Anybody got an answer?
I am going to join Sermo Doc 2's fan club here.
Macleod -- I think you are very articulate
Senator -- there are lots of ways to reform health care; most of them being considered (and all of them looking to government to "solve the problem") will not ultimately be helpful. The first thing we have to get over is the government is needed to, or even CAN fix anything here. As a pediatrician, I frequently remind the parents in my clinic that doctoring is a lot like parenting. The stakes are huge, great effort and dedication are needed, you do your very best, but there are no guarantees. The more we try to guarantee something, the worse the outcome is likely to be.
No innovative solutions ever came from a government-planned program; it didn't work for Stalin, and it won't work here. PEOPLE are innovators but only when they have the freedom and incentive to do so.
If you want HELPFUL healthcare reform, (1) stop trying to guarantee everything to everyone (including re-election); (2) allow doctors out from under 3rd-party-controlled reimbursement restrictions; (3) give people choices (on types, amounts, and locations of health insurance, health care providers, etc.); and (4) give people (including patients, insurers, lawyers, and physicians) accountability for their choices. Then, take a deep breath, prepare to perhaps not be re-elected because you didn't guarantee, but watch innovation flourish, efficiency improve, and costs come down as competition and innovation arise.
I don't understand why health car should be a federal issue. Murder cases are state issues. I favor tort reform,but this should be a state issue. American patients and doctors, more so than Europeans, expect aggressive care and to hunt for zebras. For that reason I don't think tort reform will change behavior. Lets keep it simple: Everyone must buy health insurance. It is like car insurance, portable, and regulated in the same way. It is not coupled to employment. Each state should set minimum standards for the coverage. Cost-effectiveness is improved when it directly correlates to each state's uniqueness. Like car insurance, companies can compete for the business, and rate people to pay more for risky behavior that costs money. Just as states have a mechanism to take care of drivers that cannot get insurance because of past driving records, health insurance companies can be required to accept a percentage of those enrolled, of these high risk patients at a rate that is some percentage of their lowest rate. This will incentivevise them to charge enough so that they can cover the high risk patients, because they know that they will get stuck with them later.
Although I see this as state programs, we can improve compliance. Employer are mandated to deducted from their pay pre tax and paid to their chosen insurance company. Those now covered will receive the health insurance money now paid by the employer to the insurance companies. If the new chosen insurance is less than what was paid before the money goes to the employee (The employer can be comfortable knowing that he will never see his health insurance bill increase). Those not covered will have the money for the minimum state required coverage deducted pre tax. For the generation who paid for Medicare, that money Medicare can pay to their chosen insurance company up to the amount of the standards set by the state. Every one else must pay for themselves, pre tax.
But what if you can't pay? Those below some percentage of the poverty level will need government help to pay, like Medicaid, but on a sliding scale. Some states may choose to get bids from different insurance companies to get the contract to cover these subsidized plans. For the really poor, rather than Medicaid, I would like to see a return to public clinics for the poor, like we had before 1950, to be staffed as they once were: All physicians (from the top and the bottom of their class) are required to give 5 hours a week. It would be healthy for all of us, not just physicians but also Therapists (Physical, Occupational, etc). The clinics can be run as the state wishes and staffed by the state. I would recommend a staff of nurse practitioners to compensate for the demand and shortage of primary care physicians.
Those who do not comply have broken the law. They will get emergency treatment. They will also get fined as they would for breaking any other law. Wages can be garnished until the bill is paid. I am sure lawyers can expand this into a longer document but not 100 times more than the US constitution, costs trillions, and disenfranchises us from making our own medical decisions.
We're excited that the personalized genomic medicne is thing to come, now I am afraid it may be killed before it is born by the comparative effectiveness research (CER).
Iressa was approved by FDA in May 2003 based on the surrogate endpoint of tumor shrinkage in 10% of treated patients. FDA restricted its use in June 2005 after further trials failed to demonstrate survival benefit. However, this is not the end of the story. It was subsequently found that a mutation in the tyrosine kinase domain in EGFR correlates well with responsiveness and tumor-free survival to tyrosine kinase inhibitor, and not all EGFR mutations are equal. Life is much more complicated than we thought.
Lung cancer requires individualizd treatment and subgroup patinets, such as women, non-smokers with adenocarcinoma can do quite well. The potential benefit of this subgroup patients will be denied by the CER.
I bet each and every physician here can provide hundreds of examples showing the folly of CER. As many have said that medicine is complex, dynamic, and fluid; life would be much easier and simpler for us if we can practice medicine and provide the best care possible to our patients simply following the guidelines from CER.
Thank you for your interest and my apology for the impolite comments above. It is a mystery to me why comparative effectiveness research is controversial at all. Too much of what we do in medicine is based on expert opinion and not enough on cold, hard science. Any entity, be it private, nonprofit, industry, or governmental that adds to the body off knowledge is welcome. Sir, I think your cynicism about the federal government's intent in such research is misguided and I would encourage you to not let your idealogy blind you to common sense idea that we physicia need to learn how to do it better. I think doing it bettter usually saves money. But more importantly, we neeed to know what is effective. Once we know wht works and how well, it is sound public public to have a discussion on how much we value the outcome and if the cost is wirtg. Resources are not unlimited.
Finally, sir, if you are trully in search on enlightment on comparative effective research, get opinions from numberous physician groups, not just Sermo.
Here's some feedback from this Sermoan (Sermo Doc 130):
>rarmstrong=Agree & concur, passim;
>olddoc2, 11/04/2009, 4:39pm=Masterfully succintly stated as well as correct & accurate!
>sgmor, 11/04/2009, 4:55pm=Why would a 'public option' not prove as unaffordably expensive as our present system without reforms suggested by olddoc2 (e.g. med-mal reform being the leading one).
>surgonc. 11/04/2009, 4:19pm=OK, maybe--just maybe--Comparitive Effectiveness R&D, within reason, might help to contain costs (at least over time) but vide infra OpticsThinker.
>OpticsThinker, 11/05/2009, 10:00am=Identified the med-mal impediment to CERs (i.e. the plaintiff attorney citing individual pt risk factors) but maybe this impediment might be overcome by what another Sermoan (whose 'thread' I cannot locate just now) suggested, i.e. in the State of Maine, adherence to Comp Effective guidelines may be used as a 'shield' (or 1st line of defence) against malpractice litigation.
>Sermoans in general: Hey, OK the polling questions probably are kind of inane but the real merit of Sermo is not some silly polling questions but, rather, the 'add your comment', the forum of discussion (as hyperbolic as some such turns out to be).
Senator Cornyn: Thanks for at least listening to the medical community at large. Here's a thought: why not suggest to one of your Liberal Left colleagues (Chuck Schumer of NY or Kerry of Massachussetts come to mind) that they post an opinion poll & discussion on Sermo--should prove interesting, if only for purposes of contrast!
Senator, I have voted for your party many times, and continue to do so, so perhaps you will find my opinion not partisan motivated - the questions asked don't capture the full flavor of the issue, which we are all highly opinionated, and motivated to discuss.
Compartive effectiveness is in my mind another "paradigm" BS word capturing an important idea and then offerered as a majikal balm to solve problems poorly appreciated and less understood to individuals with way too much power.
Research to make us a better country is vital. We dont want the russians beating us at our own game. Cleveland clinic and Mayo clinic draw royalty from around the world yet our free market system is being cited by those with upturned noses as falling behind countries that didn't have the courage to stand up to terrorists. - Freedom fries anyone?
We can't allow this shame to stand, else we deserve to lie down and take in the head. The united states, although stunted by the past severel years is not so far gone that this cannot be mastered.
Research in the proper hands, used the proper way is the cornerstone of a scientific community that has drawn royalty. Comparative effectiveness could help us know if lower cost therapies are just as good as more expensive ones. This could give us backbone to stand up to self serving patients who will not accept generics (MA patients are the worst). better yet we could stand up to self serving lawyers, and the same ventures that has served a long term corrosive effect on parsimonious therapy.
I am a physician, so obviously I would be biased to eliminate any hinderences to my well being. Therefore anything I say regarding tort reform will carry no real weight with most reviewing my statements.
I believe you may have already stumbled upon the solution. I do understand the SGR voting was not acceptable to the GOP. I was surprised as GOP usually supports those at higher tax brackets. I realize however parsing out the continued payment of MD's what it already costs - into another bill was a cheesy trick to hide the enourmous cost by the Dems. I'd rather not delve on the upcoming vote, as views of both parties have been well represented here (and I apologize for my uncivilized compatriots - but if it is OK for them, it should be OK to cite when the president is "mis quoting" again.)
Back to the SGR. I now call it the SGR bomb. The ticker set by a certain individual who made me a republican years ago. It continues to tick.
You see, the public thinks doctors cost too much, and should be sued. They are not worried that unregulated litigation poses them any threat.
They need the SGR bomb. When it goes off, My practice rates a 40-60% chance of ceasing to exist. I already refuse new MA. Will I have to refuse Medicare?. Ah the suspense of it. I've learned that raw capitolism is a bit irrational. Many will think doctors are paid too much even when the last doctor's office is closed. Then, just as the stock market has done so many times in the past, it will whip the other way.
I open this 3 day old email tonight, Sunday as, literally- as we speak, on CNN the Congress men and women are voting already. I mention this to say reaching out to doctors who actually see patients "on the front lines" has been essentially an afterthought in a process that has been going on for many months. Most of the input from doctors to date has been from those who make enough to worry about tort reform. They pay huge malpractice insurance policies because they can afford to and the insurance companies will keep collecting these premiums as long as they can get away with it. Be honest. The true benefactors of tort reform are the insurance companies, not the majority of practicing physicians. Don't pretend you are doing all doctors such a huge favor by saving the insurance companies money. Primary care physicians who work primarily in the office "on the front lines" and haven't been sued repeatedly don't pay but 5 - 10 thousand a year for insurance. Many times they don't earn in a year what the tort reformers pay for malpractice. For more insight into the thoughts of primary care docs I urge you and those reading this to read a couple of other postings here on Sermo and check out what a significant few of my colleagues and I are thinking.
Hopefully more will chime in on the conversation and let you people know what's really going on.
As for defensive medicine, except for settings like the emergency room, defensive medicine is also a minor problem. If more patient encounters were in the doctor's office or provided by doctors who are familiar and have rapport with the patient there would be less defensive medicine. Over the past several decades, the practice of medicine has evolved from the practice of what's good for the patient to the practice of "what's covered." To often, if it is not covered it does not get done. "Not covered" is seldom synonymous with not appropriate or unnecessary as the more marketing saavy insurance industry would have the politicians and public believe. In fact, the ongoing debate is largely about who will be covered, what is going to be covered, and how it will be paid for-or more precisely- where will cuts be made to cover the additional expense. It is not accident that people who actually see patients for a living all day every day have largely been excluded from the conversation. Because the people involved don't run private offices or actually see patients-including the doctors involved, the debate has not considered sufficiently the concerns of primary care doctors regarding the logistics and economics of patient care. Specialists and surgical types, more notably represented by the AMA and those in the political know, who make enough to worry about tort reform have been included in the conversation as if their interests were representative the other 80% of the profession. The politicians (who get huge campaign donations from the insurance companies) and hot-shot docs are busy talking about tort reform. But no-one has addressed the potential mass exodus of 40-60 year old primary care docs after they cut the budget for everything but highly specialized procedures performed by people who pay high malpractice premiums. The tort-reformers aren't going to renew all those prescriptions for generics instead of a better drug. They aren't even going to do the paper work to obtain "prior authorization" so the tort reformers can get paid for a consultation or collect 4 or 5 figures for a 30 minute procedure. It makes no sense for a doctor who gets $40 for an office visit to have to spend hours doing paperwork so a drug company can collect $200 for a prescription. This whole healthcare reform debate is meaningless if these type concerns are not addressed. When Granny gets a fever on the weekend, no one going to call President Obama, nor anyone worried about tort reform or defensive medicine. It is a shame that whoever has to workup her fever will have to spend time worrying about which insurance she has and "what's covered."
The truly important concerns that should be emphasized in the healthcare debate pertain to the reasons why people don't have a doctor and why there are too few primary care doctors and why people have no choice but to go to emergency room for care. The lack of available preventive care and cost-effective management of chronic disease has not made anyone's agenda. These concerns have largely been ignored.
The concerns about medical liability reform and defensive medicine are more the concerns and priorities of the insurance companies. If there is to be any meaningful comprehensive healthcare reform, there needs to be at least a feigned interest in the concerns of those who will provide the services that your campaign contributors don't want to pay for.
How many hours do we normally spend trying to get tests or treatment that we really feel our (normal, NOT one size fits all) patient authorized, and how many times is it mandated that we try this, that or the other before we try what is likely to work, not to mention ordering things that DO run up the costs "just because we are told we have to"? Plenty!......by the way, I DID spend almost an hour trying to get a 5 day course of prednisone, a very very cheap generic drug authorized by Title 19 for an asthmatic (treatment with this is pretty standard) when the cost of the med was probably less than $5. THEIR administrative costs, plus MY time value......consider the cost difference!!!!
AS long as when we follow these evidence-based guidelines and an adverse event occurs, we are immune to any malpractice litigation, I would consider it. Under the current system, medical liability is not about competence, it's all about compensation, and who a lay jury is more likely to believe.
I do not believe that most lay juries know much about medical competence or care about evidence based guidelines. They are guided by the patient's injuries shown to them by a skilled malpracice lawyer and the resultant consequences to the patient and his family.
The emotions of the jury, which is not a jury of "peers", play a much greater role than can be controlled by factual evidence.
A common misperception by Congress and the lay community is the idea that if you have insurance you have health care. Wrong. Many of my colleagues will probably not participate with this single payor plan as its reimbersement is tied to Medicare rates...which is scheduled to be cut back by 21.5% inthe next 4 years. And with the 40% increase in tax of most private health care plans, we will see the demise of private insurance. And the financial burden being shifted from private to the public sector.
In other words, we will all have insurance, but none of us will have doctors.
This is not an attempt at "one size fits all." It is much like the USPSTF which is an extension of the Cochrane method of evaluating data to date. Note that even the "guidelines" of many specialties are noted as manifesting much "expert opinion."
Meta-analyzes attempt to provide more robust information by reviewing mulitple studies in a cogent manner. It is important to understand the difference due to the very nature (entry criteria) of the studies - e.g. UKPDS/DCCT=EDIC v ACCORD in the very diagnosis (and prior treatments) of a disease with long term complications; or difference in protocol and potential effects e.g. ACCORD v ADVANCE.
In short, you will save MUCH more money by eliminating defensive medicine than by screwing the doctors with lower reimbursements. The problem is more complex than you may think, however, because for more than a generation, we have had paranoid doctors training new doctors to behave in a paranoid manner. One doctor who trained me ended every encounter with the proclamation 'well they can't ding us for that'. He was wrong, he still got dinged.
Shame on all of your colleagues who have left us without protection. We have dedicated our lives to caring and noone in washington cares about us. We are a precious resource and you are squandering us.
Dear Senator Cornyn, Please ignore the rude responses from some of our colleagues. I had the opportunity to meet with my representative this summer. Although I heartily disagree with her on just about every issue, we were able to have an entirely pleasant and polite discussion about the topic of healthcare. There is no need to devolve into uncivil behavior.
As for guidelines: I work in the ER. On the one hand, guidelines do assist in creating a decision tree. However, final decisions are dependent upon individual needs. For example, when the much-touted pneumonia guidelines arose, they required antibiotics and blood cultures within 4 hours of arrival. Sounds great, right? Well, there's a few problems. One, not all patients with pneumonia require hospitalization. If they don't require hospitalization, they usually don't need cultures. Two, some cases were not diagnosed in the ER - but we were held accountable for failing to provide antibiotics. This is a very simple example.
In the ER we aren't usually faced with the myriad of choices other specialists confront, but there are still "game-time" decisions: whether to send the 96 year old with gait dysfunction home at 10 PM; whether to give thrombolytics or transfer the MI to a cath lab; whether to intubate the CHF patient or use BiPap. You make these decisions with your patients. No bureaucratic guidelines determine my choices in those situations. I stick with science, even if the government has yet to catch on.
comparative effectiveness is NOT "one size fits all" but rather an approach to eliminate procedures and therapies that are either not effective or no more effective than other less costly approaches.
It goes without saying (and it seems to remain unsaid!) that tort reform must be undertaken. The failure to bring this to debate is an abomination.
Please do NOT ignore rude responses. It is just a simple barometer of the anger of physicians against the politicians, lobbyists and AMA. AMA does not represent practicing doctors. AMA has essentially hijacked the professionals who really work for a living. BTW..please take a 2nd look at the inner workings and membership of IOM...Get serious about abolishing malpractice and instituting a no-fault indemnity for medical mishaps(occasional bad outcomes are inevitable in real life medicine)
Senator,
I would like to believe that you posted these questions because you (and others) on the hill really are concerned, however I can't bring myself to overcome my skepticism.
We are rapidly creating a system where the brightest and best are avoiding medicine a profession and soon we will find ourselves being cared for by NPs, PAs, and Nurse midwives completely. I was a PA prior to medical school and can tell you, -- they are invaluable but the education does NOT compare! More and more new physicicans are " part - time" and I can tell you, there is no way you can learn the ART of medicine and practice efficiently by "dabbling".
The idea of "evidence based " medicine sounds wonderful, but it does make me cringe. If everyone has to follow the "outline" of evidence based treatment, how does one take into consideration of the ever varying responses of each individual to treatments and further more, how is anything new or better ever discovered if one is fearful to venture away from the accepted "blueprint"?
The government is making it near impossible to afford to keep a practice open. I live in PA where malpractice is a disgrace and this year our Governor and the state legislature agreed to raid the "M-Care" fund that doctors pay into every year to subsidize malpractice claims for the purpose of balancing the state budget. Now, if that isn't a TAX for simply being a physicican, I don't know what is!!
One last point --- last year the Blues contacted us and told us in our practice that they were not increasing our payments in our fee schedule. ( We have been waiting and asking for a new fee schedule for over 5 YEARS). Within the same month, the Blues also informed us that our premiums for insuring < 14 people in our office was increasing over $50,000 dollars. There you are - We don't need health care reform, WE NEED INSURANCE REFORM.
Senator- I have read most of the above remarks, and agree with the following: 1) Tort reform must occur. No fault insurance offered to all, with expert panels of MDs and judges to decide fault and compensation will save over 100 billion yearly. Eliminate trial attorneys, and malpractice costs will decline, and compensation for bad outcomes will improve. 2) CER- Sounds good, but will be subject to abuse by government. Yes, guidelines are acceptable, and yes, best treatments should be sought and promoted. However, when big govt gets involved, a la Medicare, guidelines transmogrify into punishment and then banishment from the program, and possibly criminal sanctions (see RACs). So if utilized they must be separate and distinct from the government entirely. Many, many issues in medicine have not been and will never be studied via CER. Some could not be due to the simple liability of doing so. Would we ever try to wait longer on antibiotics for appendicitis? It is not as simple as the bean counters would like everyone to believe. And therefore I believe there is danger in allowing them to try to codify and enforce the art of medicine. Thanks for your time Senator.
Each time I read about the so called unnecessary tests I realize that politicians don't know what it is like to practice in the northest. Patients here will not agree to anything without every possible test known to man. I have had patients with quite obvious diagnoses who refuse to have surgery unless they have a CT or MRI or both. If you don't get these first, they threaten to file complaint with whomever will listen. Then, if you were brave and did get them to forego the preop testing, and they then have a complication your ass is on the malpratice carpet.
The battle cry of health care reform is at best a farce. We currently have a system that most people are happy with. Cost of this care has become somewhat of a problem. So have expectations of the public. They have had access and even demanded rights to expensive technology, drugs, and treatments all at little or no cost to them.
Some changes are needed:
1. Axe pre existing condition rules for non coverage and waiting periods- The house bill that passed even has this in it. What's up with that??
2. When you switch jobs- insurance should be portable.
3. You should be able to buy insurance across state lines. This should lower prices.
4. Small business and individuals should be able to form non government sponsored coops to increase the risk pool.
5. Tort reform. The house bill prohibits states from capping awards and limiting attorney fees without suffering economic repercussions from the feds. Also if the attorney fees are not limited, why the hell are my fees being capped? I've never seen an attorney treated patient get better.
6. Fix the SGR problem. You cannot plan for the future, build facilities, or expand services if nothing but cuts are on the horizon. The country is aging with the over 65 group leading the way. If you have more pigs at the trough you have to put more feed in. The idea you can have medicare go from 48 million to 80 million patients over the next 20 years and only allow reimbursements to grow at the rate of GDP growth means continued cuts to providers and rationing. Physicians don't control tax policy and don't deficit spend. You should be very worried when US debt is offered on the open market and nobody is buying. Instead, rather than cut your spending, the federal reserve prints more money. Increases in money supply increases probability of inflation. The only way out of this is to increase revenue ( taxes). However, increasing the tax burden on society DECREASES GDP growth. Compare Denmark and France to Hong Kong and Singapore. Compare tax burden to GDP. Medicare and Medicaid act as insurance companies. Where are the reserves required of real insurance companies? We have an aging demographic, as does Europe and China. Old people have more medical problems and cost more money. As the young well pool declines relative to the older pool, costs have to rise. Congress screwed this up with politics instead of statesmanship and the egg is on your face, not ours. Every other business needs a profit margin to operate. Physicians do too.
6. Why is there no cost to the public on lifestyle? Smoking and obesity causes multiple morbidity and mortality problems thus increasing health costs. US is the fattest developed nation. Some burden needs to be placed on the public for bad choices. I can't take the twinkie out of your face.
Changes not needed.
1. Increase government control by people that are not practicing clinicians.
2. Why are we overhauling a system that works for 270 million to insure 45 million when 15 million are here illegally, another 5-10 million could have insurance and choose not to. 20-25 million are too poor or too sick. A possible role for the government would be to act a re insurer for catastrophic loss. In Kansas, you buy malpractice commercially up to defined limits and you pay into the state fund for higher limits that seemed to stabilize prices. We can fix what is wrong with this one without socializing the country. Every one points to European health care. Show me a European country that is not more socialistic than the US.
3.CER's Not that research and guidelines are bad. Non physicians love guidelines. The problem is they don't know if they are looking at good ones or bad ones. They don't look at the underlying research and the biases of who put them out. Thus guidelines are treated as de facto law. I once had a medical director of a insurance company, trained as a proctologist, arguing with me (PM&R specialist) as to the experimental nature of electrical stimulation( it has 50 years of use and data). I told him the data did not support his position. I told him not to tell me how to do rehab, and I wouldn't tell him how to treat a**holes. The stimulator was approved.
4.Payment rates less than the cost of providing care. We need more rather than less physicians. The cost of medical education and the poor reimbursement situation- who's going to go into medicine? Maybe if we got the same retirement and health benefits as you do, we may not have to worry about our future so much. I AM amazed at the boldness of the political hypocrisy. Offering health care reform. Telling the masses how it will save the country. The politicians aren't willing to mandate government employees and themselves be on it. Quite frankly, that's BS. If its good enough for us, its good enough for you.
Thank you all for your time and input. I appreciate so many of you completing this survey and leaving such insightful comments. I plan to share your feedback with my colleagues in the Senate so that they too can hear the perspective of practicing physicians in this country, not just the special interest groups that are vocal in Washington.
I had hoped to be more responsive to some of the comments and questions raised in this discussion, however the recent events at Fort Hood in Texas have consumed most of my time over the last few days. I ask for your understanding and prayers for the victims and their families. I look forward to continuing the discussion with this community in the coming weeks as Congress continues to address healthcare reform.
Senator Cornyn: Thank you for your interest in our input. We all join you in expressing our sorrow and support for the victims and their families.
Best wishes
I believe that this is one very central issue to overall healthcare cost and one of many which is not being addressed by the "fix-it" folks in DC. I fear, however, that this is one sacrid cow which will never be put to rest in my lifetime. It would take a complete restructuring of government before the trial lawyers would ever let this thing go. They basically own our government as it is.
GB
Senator,
Thanks for your time and input. Some basics are important and good to return to whenever things get too complicated;
1. VA Info System- Can't we give this to everyone who practices healthcare. Government could keep up and would need IT folks to work on protections, but easy to see, could be billed automatically, and reduce reduplication. The government really wants to help, this is one way!!!
2. Self-responsibility- Until folks are in charge of paying/managing their care through aaccounts which they are responsible for/manage, no change in costs. healthcare is one of the only things that the provider and recipient often don't know the true costs of.
This has to change with some carrots being used.
3. Malpractice-talk to senator Coburn about ideas Sermo folks have given. MDs should be punished for urely blatant things (sex w patients/rampant fraud). However, when did malpractice become the source of wealth. There has to be a balance!!
Thanks for your time and keep up the good fight. We also need to hold the insurance companies responsible. A staff member told me insurance is like toothpaste, private insurers squeeze the tube and put extra paste on their CEOs/shareholders plates and government spills the paste in the sink (waste)!
Can your survey be any more biased and leading in its questioning?!?
All you need now is a link to donate money to the GOP after instilling the fear of government takeover into the trembling right wing docs on Sermo.
The idea of comparative effectiveness research is so ridiculous that it is almost laughable. To think that some panel in Washington will help physicians avoid litigation by publishing a laundry list of best practice recommendations is just folly.
There are very few things that we do in medicine that we all agree upon. And to add to that, medical care is a dynamic, fluid situation which is constantly changing.
We all look to consensus guidelines in our practices daily to help with critical decision making. Most of these consensus statements are the result of years of arduous work on the part of researchers and clinical investigators. These things just don't appear because congress wants them.
For example, we have guidelines for the management of gastro-esophageal reflux and for the management of thyroid nodules. I use these guidelines daily, but they took years to develop and are still changing.
This comparative effectiveness push is just a cover to avoid true reform of our malpractice system. I'm sure that you know this. Now, let's do something real about it!
1. deeply involved - JOHN, WHERE HAVE YOU BEEN in ALL of these years!
2. bring down the costs of health care... How much is your CO-PAY at your last visit!
3. increasing access for millions of Americans - 12milllion (but they have health care access)... .. WHY do you need their votes???
4.. medical liability reform and the practice of defensive medicine - More... XANAX to go to sleep!
5.. "people who wrote [the bill] did not want to take on the trial lawyers" - They (Washington/Congress) RESIDE in DC dont need the trial lawyers... they are in BED with them!!!
6.. Former DNC Chairman Howard Dean - He is an AUTISTIC former PEDIATRICIAN stilll fuming!
7. . "increase the federal government's role in comparative effectiveness research to determine which treatments"... BOARD CERTIFIED politicians who need to SUPERVISE idiotic docs like me!
8.. "value the perspective of practicing physicians"... WHAT!!! , hmmmm never heard before!
9. "evidence-based medicine"... STILL DRUNK in the middle of the ROAD clinging for dear life!
10.. "opinions and insight are critically important " ... SOS for another DC bailout because docs are LEAVING and looking for another job!
"one-size-fits-all" - LEAVE the DOCTORS ALONE.... they know what to do, thats why they became doctors in the first place!!!! NOT CHIROQUACTORS!...
PS .. SERMO docs voices earlier... were thrown into the WH GARBAGEand still fuming GARBAGE medicine!!!!!
Thank you for your interest in this aspect of the healthcare discussions. I agree that malpractice reform is essential, and you state that it has been a success in Texas--can you show us the numbers, though? Others have stated that the tort reforms done in TX and CA are evidence that reform doesn't save much at all. I'd welcome data, if you have it.
In Cardiology, we have taken the lead in having well developed and tested guidelines and appropriateness criteria for most of what we do in Cardiology. We have guidelines for heart attack care, heart failure, angina, pacemakers, echocardiography, stress testing, heart catheterization, bypass surgery and many others.
With utilization of these guidelines and appropriateness criteria, we have seen a decrease in morbidity and mortality from cardiac diseases over the past decade of 27%. Instead of using our proven criteria, the government has ignored the ACC and ignored our data and has decided that it needs to do its own comparative research. What that tells me is that the government does not want to do what saves patients lives, but what will cost less money.
It is time that your colleagues in Washington start doing what they have been elected to do, take care of their constituents!
Again, thank you for listening.
Having politicians who have no clue about medicine write a list of how to practice medicine with each diagnosis is absolutely ridiculous. I am in pediatrics in a major medical center where there is a lot of antibiotic resistance. What is required to treat my patients is far different than what is required for patients in rurual America. One size does not fit all.
Yes, tort reform in TX has really helped me as a general internist in TX and should be applied nationwide.
Where I would like to see it go would be to utilize a model similar to the NIH, where CER is spread out through grants to many investigators and institutions, all with their own points of view. It is nonsenical to believe that a single monolithic institution can come up with every good idea for research and do it well, no matter how smart the people in the institution are. For scientific research, while the NIH campus produces some excellent research, many excellent studies are being done using NIH funds elsewhere in the country. While everyone has issues with who gets funded and for what, in general, this is a system that works to encourage innovation and new ideas from everyone. As noted above, created good guidelines takes time and effort, and in the current research funding schema is rarely rewarded since it is not discovery oriented work.
Better data is needed to determine guidelines. The important thing is to make sure that guidelines are flexible enough to take care of patients that don't meet the standard or make sure that failing to follow the guidelines do not constitute malpractice as is commonly thought amongst the non-medical public.
Thanks for taking an interest.
Would the members of Congress, their staffs, all employees of the Executive and Judiciary Branches be willing to accept a limitation on their care as a result of their physicians using comparative effectiveness? From where is the data for comparative effectiveness derived? What about research from one institution that does not agree with research from another? I treat a lot of sinus infections (confirmed by history, physical examination, and plain x-rays or CT. There is no accepted definition for ""sinusitis," especially "chronic sinusitis." If a study from England shows that ten days of amoxicillin does not result in resolution of "sinusitis" when the use of radiography is not used in making the diagnosis, and a long term study from a US institution shows that longer term use of antibiotics with less bacterial resistance, with confirmation of an infection by CT scan, shows that resolution of a sinus infection can be achieved, whose data do you use to develop government guidelines? How does a panel made up of lawyers, union members, and teachers develop such guidelines?
And yes, tort reform in Texas has been effective in lowering my liability insurance premiums. Without tort reform, this year's premium could have be double what it was.
Defensive medicine: If someone comes to me complaining of a headache that just won't go away and says, "I am afraid I have a brain tumor," you can bet the farm that I am going to order an MRI and refer the patient to a neurologist.
The results of that research will certainly help answer some important questions and guide ( not dictate) most appropriate practices, after all, most of our advances in medicine resulted as a consequence of research that is evidence based and was trnasmited to us during our training and through our careers as we keep up with the knowledge, unbiased research funded by unbiased agents is essential to come to appropriate conclusions.
As far as tort reform I believe every one should emulate the Texas example and is esential for an accrued savings of close to 200 billion a year, this money really do not contribute to the improvement of health care or medicine. I have been appauled to see the lack of efforts to tackle the issue in innovative ways that can both help patients and the health care system, such as the creation of no fault systems, medical forums, limitation to the plaintiff's profits and many other specific approaches about the legitimacy of an individual litigation.
I am also concerned about the fact that many areas that need to be considered, immediately if we are to be successful in implementing a health care reform have been neglected and certainly if we continue our system for the delivery of care and not develop a new and more appropriate systems of care every calculation of any budget office will miss the mark and we will end up with an even bigger deficit. The change should take place starting with the curriculum at the medical school, the trainingduring residency and the appropriate reimbursement systems based on a different approach to the care of the patients wher the weight is placed on outcomes.
1. Expansion of coverage for health insurance to the uninsured.
2. Reduction in the cost of heatlh care.
Properly conducted, comparative effectiveness trials could provide useful information to physicians. Presently FDA requires demonstration of efficacy and evaluation of toxicity of candidate drugs compared to placebo. Once a drug is approved by FDA, pharma has a disincentive to refine patient selection and to conduct comparison trials with alternative treatments already on the market. There are some notable exceptions to this but that is the usual scenario.
The problem is that no one who thinks seriously about health care reform believes that comparative effectiveness trials will accomplish either of these goals. First of all, it will take many years to definitely arrive at optimal treatment informed by well designed trials. When there is a clear winner, why would it cost less? If anything, the drug will be less of a commodity and more of a must-have. The price could possibly rise instead of fall. One could argue that by using optimal treatments there would be avoidance of complications and we'd have better outcomes. This may be true in some cases but the idea that this will significantly impact the cost of health care is wishful thinking. The bottom line is that well designed research including comparative effectiveness trials is a good idea but to tie that into the health care reform package and present it as a plan to accomplish the two broad goals is inappropriate.
Also, as you said so well, guidelines are just that. Patients are not homogeneous beings that fit into the boxes of algorithms. Well trained physicians understand the guidelines and use them to assist in delivering excellent care. They should not be thought of as a defensive move, rather they should be perceived as good medical care.
1: Public option
2: Tort reform
3: Comparative effectiveness
Stay out of healthcare completely.
End all entitlement programs,
end employer provided insurance,
end anti trust protection for insurance companies,
allow physicians to negotiate fees collectively from insurance companies,
place endless beaurocratic redtape upon legal profession with CPT type system for legal services,
allow purchase of insurance nationwide as is car, homeowners, etc.,
allow catastophic health insurance only,
make insured have some skin in the game,
serious malpractice reform,
COngress MUST have whatever they create apply to them and families 100%, no special insurance and medical access for legislators,
I could go on and on.
PS stop talking to the AMA as they do not represent the majority of practicing physicians, end the CPT codes immediately
Well, I'd like to know where have all these same folks been for all these years that Sen. Cornyn and other Senators and Congressmen have had the premier, best, Rolls Royce health care coverage that money can buy? Why were they not demanding that Congress either give us all the same deal or step down to our level out here in the real world? Why is this demand now being placed on Congress? Is it only to give more ammo to the idea that reform is bad and is another last ditch effort to demonize the public option which we all know is desperately needed?
Alternatively, Govt. should provide malpractice insurance relief for physicians.
and get Govt. out of Medical Care decisions!
Another Govt. Research Program = another Govt. Bureaucracy, another 10,000 Bureaucrats, and another $ 10 Billion down OBama's money drain!
When will it end???
Any "one size fits all" question deserves no answer. Comprehensive health reform will not lead to "one size fits all." That is a misleading and inaccurate characterization. If you're interested in "one size fits all" you would do better to look at the insurance companies and their proclivity to deny all kinds of needed care and prescribe what they will or will not pay for. They even deny patients (i.e. "prior existing condition") any care at all.
As far as tort reform, that's a complex question. Law suits do, unfortunately, lead to defensive medicine which is expensive. Capping awards saves the insurance companies money and they give some of it back to the doctors (not all of it by a long shot) in the form of reduced premiums. However, we know that there are a vast number of medical mistakes taking place each year, causing vast amounts of injury and death. I hate to see people grievously injured denied what is coming to them and what they need.
I would be in favor of a plan practiced in either Australia or New Zealand whereby doctors make an annual payment into a fund. When a patient is injured by medical mistakes, application is made to the fund and a reasonable amount is paid. This works out a lot cheaper than our current system but it doesn't deny hurt patients their due.
Senator Cornyn, I know what you are against in health care reform. I have yet to see a comprehensive health care reform proposal from your corner, i.e. what you are for. It doesn't exist. I tend to agree with Rep. Grayson of Florida. His take on the Republican position is that Republicans basically favor telling patients "don't get sick" and, if they do, "die quickly." That may be crass but it's a pretty accurate rendition of Republican health care reform.
If Congress does not include themselves, the Executive, and the Judiciary in any medical care program that passes (it must be mandatory, and not choice for the government employees and elected and appointed officials) it smacks of ELITISM, and, John, we fought the Revolutionary War to tell King George that there are no elitists in our government. All elected and appointed officials MUST, upon reaching age 65, be enrolled in Medicare as their primary health insurance, whether any "reform" bill currently being considered passes or not. An 85 year-old Senator should not be allowed to have knee-replacement surgery if no other 85 year-old citizens are allowed to have the same procedure.
And Sermo Doc 24, the Republicans have several proposals in Congress for health care reform that encompass much of what has been written here.
Will you be joining the demonstration of American people and Doctors at the Capitol tomorrow, Thursday Noon, organized by Rep. M. Bachmann (R), MN, and will you be available for questions afterwards when people circulate through the Capitol and Office Bldgs. to speak to their Congressmen about their Health Care concerns?
(See Fox News today)
Ramstrong for President! (or any other elected official unwilling to kowtow to special interests and fight the deluge of lobbyist dollars stroking Congress and other bureaucratic dullards). You express my sentiments eloquently and succinctly—minus the interjection of profanity. :-)
Can you organize anyone to meet with Rep. M. Bachmann, (R), MN, at the Capitol demonstration tomorrow, Thursday, high Noon, followed by visits to Congressional offices for talks with cell phone cameras in hand??
All Americans are welcome along with Doctors.
Be truthful, be sincere and make your case with facts. Honesty and truth are VERY powerful and are very difficult to ignore. Your congressman/woman will be impressed that you took the time to show up. It is helpful.
I do not follow paradigms prescribed by academicians (and I used to be one). Metformin is now considered the first line and most important med for type 2 diabetes, finally, 15 years after it came to the US. I was using it that way already in January 1995, the month after it hit the market here, against all the then current paradigms. Do we want our care to be 10 years out of date? Then let's follow government paradigms that do not allow us to think or individualize.
If you want to lower costs and improve care, get the government and the managed care industry out of the doctor's office.
Assuming you are taking the comments on this string seriously (or at least taking the serious comments seriously) the following points manifest themselves
1) Physicians are actually quite divided about health care reform, the best way to go about it, and what the cost savings would be. I personally agree with the need for a robust public option as a means of covering the uninsured in this country - we need to do something to stop the 40,000 unnecessary American deaths that occur due to lack of coverage. Perhaps we can at least agree on the morality of this. Unfortunately I sometimes percieve this as less of a priority among some of my fellow healers than preserving the status quo, which lets face it, is fundamentally irrational, loaded with perverse incentives, and does not provide value fo the money; value on the dollar by the way as being one of the 'conservative' principles I completely agree with
2) As the government already picks up the tab for roughly half the health care costs, to have NO comparitive effectiveness research is, again, wholly irrational. I guess I would argue this not only as my fiscally conservative nature dictates (#1), but also as a taxpayer who does not like paying for the healthcare equivalent of $500.00 hammers. Further I sort of agree with Sermo Doc 13 about the need for different institutions to participate, but know as a researcher that multi-institutional studies are often the best way to answer pressing questions. And I can tell you, as I teach health care policy at my university (among many other things) that the questions are many.
3) It is obvious that almost all physicians, right and left, agree on the need for tort reform. The current system, no matter what figures one uses is, again, completely irrational, rewarding tort attorneys disproportionately over the injured, and doing nothing to enhance quality health care
4) the American College of Surgeons has endorsed HR 3961, in part because it repeals the Sustainable Growth Rate. As I recall, you were one of the senators who voted AGAINST that repeal. Unless that goes, you will get no serious buy-in by physicians.
5) The preceding comments are written, as I have said before, under the assumption, sir, that we can take your word at face value and think you are seriously obtaining our input, rather than merely trying to score political points. If the latter is the case, than I, as a practicing surgeon, have real patients to take care of, and my time is at a premium
As we move forward in this process, I believe that we have to go beyond political rhetoric, we have to go beyond posturing and bullying and get to the root of the honest problems that plague not only our profession, but also our nation.
I believe that this is a great country. Having done some traveling internationally, there is no other place that I would rather live. I believe that we still have a functional democracy and that we still have media that cover the issues from several perspectives. I also believe that the nation, as a whole, has the ability to balance itself toward the center, where common sense lives, in issues large and small.
I talk quite a bit with my father-in-law. He is a retired pipe-fitter, dropped out of school in the 8th grade to go to work. He is 82, has worked hard all of his life and still prides himself on a job well done. If I need to fell a tree, I ask for his help. He knows just where to cut and can put it down exactly where he says it will go. He is not educated in a formal sense, but he is one of the smartest men that I know. He listens to these debates and he can point out the BS just as accurately as he can fell a tree.
There are a lot of people in America like my father-in-law. They know when things don't add up and they know when the politicians are trying to sell dreams. I think our nation owes these people honesty and hard work. I'll keep going.
Thanks Sermo Doc 26!
md.sermo.com
Perhaps it is time to help Wonposet. Can you share this with your Ohio colleagues?
Tort reform IS critical - and it is ludicrous that the Dems have avoided it so completely in order to curry favor with such a small group of Americans (who happen to give over-sized campaign contributions.)
The Senate SGR shenanigans WERE political games and the vast majority of physicians recognized it. The Senate 'repeal' would have caused far more problems than it solved. SGR still needs to be addressed, but I agree with the defeat of the previous maneuver.
CE research COULD be very helpful. BUT.... I have serious doubts that a cash-strapped government insurance plan would seriously invest in ***good*** science to get the BEST answers. I DO believe that the government would pursue CER via entities so beholden to their gov't funding that they would bias results in a manner likely to please the hand that feeds them (ie: save money.) Biased 'research' is readily available. Much of the current reform 'debate' has been fueled by publicizing extremely biased 'research' results. Just like any political poll - ask the wrong question, get the wrong answer. Health care is too important for that to become the rule of the day. Before ANY talk of seriously adopting CER influence can be considered, we should develop a plan for conducting the research in a transparent and credible format and get THAT infrastructure operating. Such a credible body of CE research does not exist today.
As for "one size fits all",this reflects the simple minded attempts Democrats and the President are calling reform.They know we have the real answers to improve healthcare,but don't want our input due to their political support by lobbyists who will lose financially..
Here are some of my concerns about Comparative Effectiveness Research and Evidence-Based Medicine.
As you may know, there have been some concerns about the quality of medical writing, ghostwriting, and guest authorship of published research papers. Sen. Grassley has been looking into this issue. The upshot of some of this has been to cast doubt on the quality of some of the published literature available. While aspersions have been cast on the pharmaceutical industry in this regard, it has also been found that there are questionable publishing and research practices in academia which may be even more prevalent.
An additional problem is the increasing tendency of universities to issue press releases in advance of a published paper, which can result in journalists, policymakers, and others writing opinion pieces and making decisions based on the superficial information in the press release, and not on the actual published data, which may not appear for another month or more.
Consensus guidelines, put together by experts in a given field, are useful--up to a point. They will not be useful if they are mandated by bureaucrats, and are based on single studies. It should be kept in mind that with every disease state, there are outliers. Many published studies exclude certain subjects, in order to keep the data from becoming too unruly. This, however, does not reflect "real world" patients. Treatment guidelines that are based on published literature will not reflect the "real world," yet these are the patients we must treat.
Please do not bind us hand and foot in our attempt to do so.
I'm really disturbed by the number of physicians who are associating themselves with the far rightwing teabagger, deather, czarer, birther types. This will result in absolutely no good for the medical profession.
Forget who puts the demonstration together even if it's Godzilla!
If Doctors and Americans can get together and protest together at the Capitol and meet with their Congressmen, face to face, with cell phones/cameras, that can effect some change.
If you like the way our Socialist Govt. is moving, stay home and read Karl Marx or watch the Marx Brothers, your choice.
I am glad for your interest in health reform, however I am extremely disappointed in your biased "push survey". Please, reconsider who you ask to develop your questions next time. The questions are insulting. As a clinician researcher I can tell you that your question has nothing to do with CER. No physician would disagree that our goal is to offer the best quality care available, most physicians would agree that having strong evidence behind our decisions is optimal.
As all of us involved in clinical care can attest, health care (and sick care) reform is crucial. In a country with the resources of the U.S., one coordinated system of care, not linked to employment or income, available to all, is our moral responsibility. I am disappointed by anything less.
We also already have Preferred Practice Patterns and published evidenced based medicine that are the backbone of competent care.
If the government wants to keep down costs, they should never have given excessive power to NPs, chiropractors, optometrists, etc. In my experience a NP seeing a patient with a mild corneal infection is much more likely to pan-consult the field with a immunology consult, infectious disease consult, and a heme/onc consult, in addition to the ophthalmology consult. It is idiotic, bad medicine, and very expensive. Chiropractors can order various imaging studies but lack the medical knowledge to A) know which test is actually indicated and B) are unable to correctly interpret them. This also adds significant expense and excess testing. Optometrists have very poor training beyond prescribing glasses and try to put every single patient in glasses whether they need them or not. There are millions of dollars in excess glasses each year that people don't even wear because they were not medically indicated. As California recently demonstrated, they are unable to manage glaucoma. If you want to cut down on costs, maybe you should start auditing chiropractor, NP, and optometrist claims first and see how much waste is there and see how much a royal mistake Congress made by ever granting them additional privileges.
C'mon--the wording is so biased! I assume your staff wrote these questions. I've capitalized the offending phrases:
"What impact would ONE-SIZE-FITS-ALL coverage decisions FROM WASHINGTON" and "how effective would ONE-SIZE-FITS-ALL coverage decisions FROM WASHINGTON"
Sen. Cornyn's staff--Check out the story from today's NPR's Morning Edition ("GOP Strategist: Obama Honeymoon Is Over") in which host Steve Inskeep asks GOP political consultant Mike Murphy about poll numbers showing the majority of the public supports a public option. Murphy's response was "you have to be very careful. Polls that test hypotheticals--would you like a helicopter in your back yard every day that'll take you to work in 4 min--you can get a very good poll number..."
So...can you show us where in any of the draft legislation does it say there'd be ONE-SIZE-FITS-ALL coverage decisions FROM WASHINGTON?
Did you think you could pull something like that on Sermo?
The other problem is that even though we have these well thought out guidlines, they are really often not followed. I see this as primarily the fault of the individual physiciancs, but there are many things that make it hard for the informaiton to be disseminated. So even thought we know a few of the answers we are not even following that.
I don't think CER in its essence is to creat one-size-fits-all medicine. It's to find answers so that we can be more respobsible, efficient and cost effective physicians. The government wouldn't have to impose this on us, if we were doing it well ourselves. And we are not. The information needs to be gained.
And there are probably some areas, some, where it would be appropriate to have some structure we are not really allowed to stray from. But this only works to a point and we must never loose our ability to make the complex decisions required in each clinical situation.
Since the NIH all ready is doing research in medicine another arm of research seems to be a duplication and I am not sure what exact measures they will be researching.
Concensus guidelines can be helpful when discussing treatment options with your patients. But frankly, I have several patients who will continue to disagree with them and do not do the recommended treatments I suggest for what ever reasons. Often times it is from distrust of the pharmaceutical industry and a preference for "natural" remedies or a lack of an ability to afford such treatments. The thing that scares me with big brother looking over my shoulder is that if those individuals do not do the recommended treatment, then I am somehow deemed a poor physician. That in turn will make me what to discharge such patients from my practice, which seems like an even worse outcome given the limited amount of family physicians availble these days. But that is another topic....(hopefully you will get to that one too)
Please leave medical research to NIH and other reputable Institutions, not the Obama Med. Research Center!
It's time to stop the rhetoric, and get both parties to agree that universal health coverage is overdue, and get to work on an acceptable compromise that gets it done (in today's news - the proposed Republican Senate plan will cover 3Million uninsured - leaving 37million still uninsured - is this a serious approach?)
There are 2 reasons why money is wasted in the system: 1) defensive medicine, and 2) patient demand. CER might help with the patient demand side - you can say that something is of no proven value, maybe they'll believe you.
The best "brake" on the #2 problem above is for patients to have to pay for tests with no proven benefit. Well, then you get into the argument of "proven benefit". So don't worry about that. Just make the patient responsible for the first $5000 of medical spending through an MSA and they will apply their own financial caution.
What gets every cash-pay patient's attention: "In my opinion that test is not worth your money right now." They're grateful, not angry, to hear you say that.
Bring back balanced billing for Medicare patients. The Gov't can't afford to pay a reasonal fee for physicians' services; so let us get the balance from the patients.
All physician contracts (M'care, M'caid, Mismananged care) should have a COLA. However; when there is no cost of living increase, I wouldn't expect an increase Mr. President.
It is quite clear from usage elsewhere (e.g. NHS's NICE) that implementation of best practice recommendations can help control costs and still allow clinical flexibility. It's also clear that tort reform is another useful arrow in the quiver for reducing total health care expenditures, and should not be ignored. We'll ultimately need all the help we can get to bring our per capita costs anywhere near where we need to be in order to keep the deficit manageable. Implement both.
Thank you for requesting our input into medical care decisions.
1. Defensive medicine is a huge problem, Any enjoyment of my specialty has been taken away by the giant litigation elephant peering over my shoulder at every film I read. It is miserable, and does result in a huge number of unnecessary follow-up exams as part of the trial lawyers' creation of CYA medicine. When are politicians going to stand up to these bullies, who control by finance and fear (true terrorism)?
2. Practice guidelines will only serve to create more paperwork-by which physicians are already completely inundated. Trial lawyers will use these guidelines to try to trip-up docs and deny necessary care to the patients that need it. MD's earned their degrees because they have the intelligence and training to make logical, informed, medical decisions-themselves.
1. delay any real action on Tort reform
2. eliminate as many primary care physicians as possible, replacing them with PAs and NPs.
I realize that the second point is controversial and not inherently obvious, so let me explain. If enough of this Comparative Effectiveness Research is done, there will be protocols for the treatment of everything, eliminating the ability of doctors to use their own judgment in the treatment of patients. If you do not need someone with a doctor's level of training, why pay for one? There is a projected shortage of PCPs in the near future and the NPs are already lining up to take our place. This is just another opening for them to exploit.
Thank you so much for coming here. I am a practicing dermatologist. As an undergraduate, I majored in applied math / risk assessment at Harvard.
There are vast amounts of money to be saved by conducting comparative trials of treatments. In my opinion, Congress can substantially reduce health care expenditures via comparative trials with a single page of law.
That page should require that all new medications and all new medical devices be compared against existing best therapies. Current FDA studies on most new medication are done vs. placebo. We do not need to know whether a new $3,000/year drug is better than a sugar pill. We need to know whether it is truly better than the $200/year generic. This will cost Congress nothing. The drug companies would simply have to change their trials, adding a comparison arm. No additional regulation would be required. The FDA already has rules in place for trials.
A concrete example from dermatology: Altabax is a topical antibiotic recently approved by the FDA. It is prescription and costs $100 for 5 grams. For comparison, Polysporin is an over the counter topical antibiotic that costs roughly $5 for 10 grams generic. Altabax has many studies showing it kills bacteria at lower concentrations than other topical antibiotics. Gram for gram, it is more effective. So, many primary care doctors and dermatologists prescribe it. But it is a scam. The actual amounts of antibiotic used in these topicals are so high that differences in the lab do not matter. Polysporin should work just as well as Altabax on patients.
Had the FDA required Altabax to be compared to Polysporin instead of placebo, Altabax very likely would have shown itself to be merely equivalent to Polysporin. And therefore, we doctors would rarely prescribe it. This would save Medicare and Medicaid millions and millions of dollars a year. Altabax, by the way, is a minor drug, a drop in the bucket. Many of the big drug companies don't even bother with topicals like Altabax because they don't make enough money to count.
If you apply this same rule to major drugs, like the antidepressants, cholesterol-lowering drugs, and blood pressure treatments, you would find that many of the "new" and very expensive drugs do no better than existing generics. Medicare and Medicaid would save many billions without changing outcomes. These billions would be saved because we doctors would not prescribe nearly as many new high-priced equivalents of good, inexpensive, generic medications.
I speculate that this would generate a huge political fight, because vast profits are being made on these drugs. However, it is hard to fight a single sentence that the public can understand:
"When possible, the FDA shall require that new medications seeking approval be compared in clinical trials against the best approved medications that are already on the market."
I will put additional comments on other topics in separate posts. Thank you again for your interest Senator. It is truly appreciated.
I agree with all of Ramstrong's points and want to add an additional angle on the tort reform issue.
In medical school we were taught how to make a diagnosis by using our clinical skills and turning to more specialized testing if we needed more information to make the diagnosis. When we got to residency, I was shocked (and insulted) to find that we were being trained to give up our clinical skills and turn to expensive testing so that we would be able to defend all of our actions in court should a malpractice case arise.
To put it another way: In the current medicolegal system, even if we have enough information to make the diagnosis, we have to order the specialized tests to confirm that we are right just to fend off malpractice attorneys. This ends up costing up to ten times as much as simply treating the patient based on clinical acumen.
Please give a board-certified physician the right to rely on his/her clinical skills without the need for the practice of defensive medicine. You will save this country a fortune.
How about comparative effectiveness research into how much trial lawyers contibute to our Gross Domestic Product?
Texas Medical Association and Texas docs put you on the Texas Supreme Court, your stepping stone to the Senate. Since then, whenever we have asked for your vote on issues important to medicine, you have walked away. When you start supporting us we will believe you are our advocate. Remember we have enormous influence in our communities (that is how you won the Supreme Court election) and we are paying attention to your votes.
I wrote you a couple of weeks ago about this issue and still have not heard back. I am not a member of the AMA, but did not appreciate your criticism of them in regards to their approach to medical concerns. From that article I read in AMA News, it did not sound like these issues concern you at all, so this forum is a surprise. You also seemed to have no trouble voting against the Senate SGR repeal recently.
Tort reform is indeed an important component in the increase in medical costs, but it is not the only one. I agree that practice guidelines sound ominous and time consuming if they are implemented like other government initiatives. If you are so interested, why don't you get involved to see that it is done differently this time. And vote the way you really feel on SGR instead of twisting with the breeze like you did in 2008.
With the above comments you are hearing the frustration and anger from physicians who have been pushed around and ignored. The problem with the system is too much money made by certain groups(insurers, pharmaceuticals, hospitals, and medical device makers,etc). Physicians have had eroding salaries and increased workloads for years. The doctors are fed up and are now forced to retire or change jobs in droves. If you want to ration care, you will do it as there won't be docs to see patients. If you want to mess(read f***) with anyone, please do it to the folks who have made a killing off the system.
The "questions" you asked are not valid. You're not at a rally of the same cowardly dim-witted yokels that you and your neo-con cronies terrified into voting for you and your ilk. The majority of the American people are smart enough to see through your lies. It's no longer just the few liberals that have been brave enough and patriotic enough to stand up to the likes of you for years. You've proven to be nothing more than an insurance cartel minion and Obama and Pelosi will bring you down.
It is a mockery of the responsibility I have entrusted to you. It is a slap in the face. I am not laughing at your arrogance. Why is it that I feel as if you would not trust me to make a single decision about my own life and how I would live it but you should expect that I should trust you with the debt that you have laid on all of us and our children. We did not want the TARP bill. We said no. We would repeal it if we could. I am sure that we still cannot. There is needless urgency and recklessness in all of your recent spending of our tax dollars.
From my perspective, it seems that all of you have gone insane. I also know that I am far from alone in these feelings. Do you honestly feel that your current pursuits have merit to patriotic Americans? We want it to stop. We want to put the brakes on everything that is being rushed by us and forced upon us. We want our voice back. You have forced us to put our lives on hold to straighten out the mess that you are making. We will have to give up our vacations, our time spent with our children, any relaxation time we may have had and money we cannot afford to spend on bringing our concerns to Washington . Our president often knows all the right buzzwords like unsustainable. Well, no kidding. How many tens of thousands of dollars did the focus group cost to come up with that word? We don't want your overpriced words. Stop treating us like we're morons.
We want all of you to stop focusing on your reelection and do the job we want done, not the job you want done or the job your party wants done. You work for us and at this rate I guarantee you not for long because we are coming. We will be heard and we will be represented. You think we're so busy with our lives that we will never come for you? We are the formerly silent majority, all of us who quietly work, pay taxes, obey the law, vote, save money, keep our noses to the grindstone... and we are now looking at you.
You have awakened us, the patriotic freedom spirit so strong and so powerful that it had been sleeping too long. You have pushed us too far. Our numbers are great. They may surprise you. For every one of us who will be there, there will be hundreds more that could not come. Unlike you, we have their trust. We will represent them honestly, rest assured. They will be at the polls on voting day to usher you out of office.
We have cancelled vacations. We will use our last few dollars saved. We will find the representation among us and a grassroots campaign will flourish. We didn't ask for this fight. But the gloves are coming off. We do not come in violence, but we are angry. You will represent us or you will be replaced with someone who will. There are candidates among us who will rise like a Phoenix from the ashes that you have made of our constitution..
Democrat, Republican, independent, libertarian. Understand this. We don't care. Political parties are meaningless to us Patriotic Americans are willing to do right by us and our Constitution, and that is all that matters to us now. We are going to fire all of you who abuse power and seek more. It is not your power. It is ours and we want it back. We entrusted you with it and you abused it. You are dishonorable. You are dishonest. As Americans we are ashamed of you. You have brought shame to us. If you are not representing the wants and needs of your constituency loudly and consistently, in spite of the objections of your party, you will be fired. Did you hear? We no longer care about your political parties. You need to be loyal to us, not to them.. Because we will get you fired and they will not save you.
If you do or can represent me, my issues, my views, please stand up. Make your identity known. You need to make some noise about it. Speak up. I need to know who you are. If you do not speak up, you will be herded out with the rest of the sheep and we will replace the whole damn congress if need be one by one. We are coming. Are we coming for you? Who do you represent? What do you represent? Listen. Because we are coming.
"We the people" are coming.
Thank you for your post..
For a good example of "one size fits all" health care, you need look no further than your neighboring state of Louisiana. For those who do not remember, Medicaid was begun to give the rest of the country what Louisiana provided with its Charity Health System. The system works, but is indeed rationed care, as anyone who was around during hurricanes Katrina and Rita will tell you. During that time, the 8 Charity Hospitals in the state were reduced to 5 in a matter of 3 weeks. Charity New Orleans ceased to exist, and the moment the computer room in the basement of "Big Charity" lost power, ALL patient medical records throughout the entire system were lost--there was no back up, there was no mirror site. I know this for a fact, because I had a solo practice at one of the surviving Charity Hospitals and remember the moment wie lost all access to patient information. It took weeks for the IT team members across the state to recover and rebuid this.
Anyone who is honest will tell you that equipment, resources, etc, were not equal throughout the system, and that care in such a system is by necessity rationed. Those with more clout get more, and others will go wanting. Charity New Orleans had a new MRI which of course became useless after the flood. My hospital didn't even have a CT scanner capable of diagnosing pulmonary emboli, and this was in 2005. Nuclear medicine was contracted out and not an on-call service. And all of a sudden this tiny hospital was serving a population greater than just the geographical area. This is what happens in a government run system. No one is turned away, but it's hardly speedy or efficient..
Senator Cornyn, Louisiana Governor Bobby Jindal has more experience with this type of health care than anyone in the country. If you are looking for information, look no further than the state next door, and the governor's office. As a former head of the Louisiana DHHS, Bobby Jindal can provide you all the information you need, including what happens when disasters such as Hurricanes Katrina and Rita decimate parts of the state as happened in Louisiana just 4 years ago, and how this impacts health care delivery in a "one-size-fits-all" population. He will know the costs, the pluses, the minuses, the strengths and the weaknesses of such a system better than anyone I can think of, and surely better than Harry Reid or Nancy Pelosi.
Other countries have tried this. It hurts the patients.
We all use constantly changing guidelines in our practices. Most of us are sharp enough to recognize when we need to deviate from the guideline in order to help the patient most effectively. In fact, that is how medicine advances and why one can receive the highest quality of medical care in the history of mankind only in the United States. Of course the statist totalitarians would want to take that away.
Consider, if you will, the frustration of the doctor who sacrificed so much for so long in order to be able to help patients, only to be forbidden by the insurance company to do what is best for a patient because their high school graduate who can spell neither the condition nor the needed procedure can't understand the patient's problem. Now multiply that frustration by thousands. That's government run tick box medicine. We physicians need less interference as we help patients, not more.
If American medicine had always used such tick box medicine protocols, we would still be receiving blood lettings and leeches -- at the barber shop. No one would be washing their hands. Millions of women would still be dying in childbirth.
Of course, it seems that it might be cheaper. It wouldn't. Not only would the individual whose condition is unusual or less common be hurt, the failure to treat the patient optimally would lead to more illness and more cost, both in terms of more medical treatment and reduced productivity.
Every specialty organization currently uses and updates best practices guidelines -- as recommendations for the common situation. How do bureaucrats who lack the training and experience know better?
In those cases where their protocol fails, will the bureaucrats pay the malpractice claims? After all, they are now proposing to practice medicine -- the second they begin to enforce their protocols.
Thank you for coming here and getting input from practicing physicians. With all due respect, having politicians in Washington, who are for the most part backed by unions and lobbyists, redesign 1/5 of the US economy is a travesty that is being forced on the American people under the guise of "taking care of the 47 million uninsured". You and I both know that number is hugely inflated, and adds in illegal immigrants, who should basically be shown the way home, not given more free benefits. It also includes people who 'choose' to not have insurance, and if I remember correctly the USA is still a free country and as such should not have the government force policies on the people. Period, end of story. Additionally, taxing the people who actually provide jobs and produce in this society to pay for those who don't is not a way to foster excellence, or create jobs. It is a way to drive down excellence, reduce jobs and foster mediocrity. When is Washington going to remember what made America great? Self reliance. Self determination. Personal responsibility.
Having gotten that off my chest, let's talk about comparative effectiveness. While in theory, this sounds good. In practice a 'one size fits all' approach to care is just a way to subvert the doctor/patient relationship with government edicts. Additionally, these studies are a perfect petri dish for more government corruption. Doctors and patients, working together as a team to improve health, has worked effectively in our practice for 25 years.
A large part of my practice is teaching patient how to care of themselves, and making sure that they do it. I have helped over 1500 people turn their lives around, lose weight and get off BP/cholesterol meds and reverse their diabetes. How's that for reducing costs? Imagine if doctors were able to put the efforts into getting people healthy, rather than just managing conditions. What would that do for cost containment?
True cost reduction will occur when their is tort reform, and allowing insurance companies to compete across state lines for business. Putting doctors on a Medicare fee schedule will result in fewer doctors. I have been treating people over the years who for one reason or another can't pay their bills, usually due to some sort of financial hardship, but I can't write those services off of my taxes. How about allowing doctors to do that? I am sure that most of us would be happy to take care of these people if we could write those services off, and it would not cost the tax payer one cent. There is your coverage for the 'real' uninsured.
There are a great many 'real world/free market' solutions to health care. The answer is not in Washington, with politicians.
There is no doubt, that we are the flavor of the month because we offer an opportunity to make Obama look bad. I don't mind Obama looking bad, but he seems to be able to do that all by himself. Only the most naïve of us believes that the Republicans care about the welfare of physicians or their patients. They won't respect us in the morning. As an excellent example, remember that Sen. Cornyn is a lawyer, a former judge, and a former Texas Atty. Gen. He does not need to know what a poor malpractice environment does to physicians. He already knows. His inquiry is for the most part, designed to draw attention to himself, and portray himself as a man of the doctor folks!
That said, his question has been repeatedly answered by many more articulate people than myself. No one knows how much money could be saved in a healthier malpractice environment. There has been ethical slippage amongst physicians, which although caused by a poor tort environment, as well as a dismal reimbursement environment, may not be reversible. When it became okay to order unnecessary tests, and diagnostics, to protect against possible future litigation, it was one small step over the line that made it possible to order unnecessary tests to increase reimbursement. To be sure, there have always been physicians who did unnecessary testing, for example CBCs and chest x-rays on every patient , but it never happened on the scale that it does now. In my community of 20,000 we have three group practices that have all become experts on churning every possible dollar out of every patient. This is happening because of our dismal reimbursement environment, but it became ethically okay because of defensive medicine. No physician, on any survey, will admit that that's the case. No cardiologist will admit that he has done unnecessary angiograms. No orthopedist will admit to doing joint replacements that he knew would not help the patient. These are the times in which we live.
One of the writers above noted that In capping malpractice awards we are not reforming the tort system. The system continues as it always has. It still rapes every physician who is accused of malpractice. No physician who has been accused, regardless of the outcome, practices the same way afterward. True tort reform would require a paradigm shift in the way patients and the legal system think. Frankly, I don't believe we have the ethical environment amongst politicians, or the intellect amongst politicians, for that to happen. Without meaningful change in the tort environment,defensive medicine will continue, and those savings will never be appreciated.
As to comparative effectiveness, it is another attempt to turn medicine into a cookie-cutter business. This started when Medicare attempted to adapt the work of W. Edwards Deming on total quality management. Deming, who was an expert on tweaking process to get maximal effectiveness, was never consulted on applying his work to medical care. At one time, he did comment that would be a very difficult thing to do. Some of his work has been adapted to shorten length of stays on, for example, joint replacement surgeries. At this time, there is ongoing research in attempting to eliminate recidivism in COPD patients. I've not seen any outcome. There does appear to be some utility in the work, on a microcosm level. The idea of applying it on a macrocosm level is horrifying. It would be enormously expensive, would require intellectual leadership that does not currently exist in our government, and it would require a total commitment on the part of physicians, patients, and even lawyers to accomplish.
By the way, did anyone notice that the whores that run AA RP just sodomized their own members by endorsing the House health care bill. Just amazing!
Again I thank you for coming here. I am the dermatologist with the Harvard applied math/risk background.
You ask about defensive medicine. This is a huge problem for doctors. The issue is we cannot guarantee good outcomes. Even with a very harmless-appearing mole, for example, no dermatologist can know for sure that it won't become a melanoma. So we manage risk with every decision. If the risk appears miniscule, we do nothing. But often the risk appears merely "very low" or "low," in which case we must think about whether we could get sued if we don't order the full workup.
Take a patient who comes into the Emergency Department with a headache after falling and banging his head. The doctor assesses him and decides the chances of him having a brain bleed is "too low to justify a head scan." What happens if he releases the patient without a $2,000 head scan and the patient has a bad stroke from a brain bleed? The doctor will get full blame for being "wrong." Well he wasn't wrong. He assessed the risk as "too low to justify a $2,000 head scan," not "zero."
Knowing he could get sued if the patient has a rare bad outcome, the doctor starts thinking about the patient. Is the patient the suing type? Is the spouse demanding a head scan? If so, then many times the doctor will order that head scan. The head scan does not benefit the doctor financially: he neither makes nor loses money when he orders one. But he does benefit from peace of mind, knowing he is now in the clear should a hidden brain bleed cause problems later.
Fear of lawsuits changes what we do. An example from dermatology:
If you take 20 moles off 20 teenagers' backs today and send them in, many of those moles will be called atypical by the pathologist who reads the slides. If you took those SAME moles and transported them back to 1990, the 1990 pathologists would call far fewer of the moles atypical.
In other words, the pathologist's definition of what is "atypical" in a mole has changed radically. Minor features that used to be considered normal are now called atypical by many pathologists. From a numbers perspective, the number of moles on all Americans didn't change much, but the percentage of those moles that would be called atypical perhaps tripled or quadrupled (my guess, not studied numbers).
What changed? What happened was a couple pathologists got sued when "slightly atypical" moles turned into melanoma and killed people. The pathologists effectively called the risk "very low, and not justifying cutting out a big piece of skin." They were correct. Bu the risk was only "very low," not "zero." Since they looked at millions of moles, it was bound to happen that a few "very low risk" moles became deadly melanomas. This is similar to playing Powerball: if enough people buy tickets, someone will eventually win. The lawsuits were lost, and the pathologists got nervous. What if they called a mole ok, but the pathologist who reread the slide for the trial lawyer said "No, this is slightly atypical, so he should said to cut it out if it comes back."
As a doctor, after you lose a night or two of sleep over this, often you just go with it and start calling more moles atypical.
Again, nothing changed except the pathologists became more afraid of getting sued, and then starting calling vastly more moles atypical.
So what was the result? Far more moles are getting biopsied now. Far more biopsies are ending up with the dermatologist having to go back and cut the moles out. This should never have happened. We have better clinical diagnostic techniques than we used to. Using a handheld microscope called a dermatoscope, we dermatologists are now considerably better than our colleagues were 20 years ago at figuring out which moles are bad and which are ok. But we do many more biopsies now. Why? A few lawsuits were successful, we became afraid, and we know that even though the dermatoscope says it's ok the pathologist will probably call it atypical. So I ask myself, "Do I want to risk bankruptcy and losing everything I have worked for for 20 years over this mole, even if it is a small risk?"
In a word, no.
Tort reform has to be included now or it never will be.
Sermo Doc 23, Rep. Michelle Bachman??? Are you kidding? That particular individual is borderline if you ask me. sgmorr gets his instructions from MSNBC, because anyone that has actually heard Rep. Bachman talk knows she is informed and very bright.
There are already organizations establishing "best practices" to treat illnesses and improve patient safety. Keep the feds from becoming more involved in the practice of medicine than they already are!
If your are truly interested in having a health care system that benefits the people of the country, and requires the least expenditure of GNP, please read the above comments carefully. Most of these suggestions have a tie to realities that are being ignored in the current partisan debate.
1. Statistics deal with populations, not the individuals within that population. Guidelines / protocols / "Evidence Based Practices" provide checklists of what should be considered, and more importantly when to change course and consider alternatives:
a) Individuals need care for their individual problem. There is no way to know in advance whether an individual patient fits the established paradigm.
b) Medical knowledge expands from investigation of exceptions, not repeating failed solutions. I won't comment here on other segments of society.
Pre-flight check lists do pilots little good after takeoff when something goes wrong. The investigation of exceptions must be encouraged, and financially supported. The time and effort required to thoroughly deal with a patient doesn't fit into one ten or fifteen minute office visit.
2. Tort Reform is essential! Add the Trial Lawyers to the list of people with immense profit from the health care budget with no actual responsibility for providing that care. Note, that if everyone's health care needs are covered by a universal coverage system, injured parties, whatever the cause - auto, medical, or negligent sidewalk repair - will have mo medical care cost requiring compensation. That leaves compensation for lost income and property, and prevention of recurrence at issue. Surely, these determinations are not best made in court, or when extraordinary judgments compensate attorneys far more than the injured, at the expense of the insured - premiums go up. Insurance companies are in business to make profit and pay executives.
3. The least expensive per capita cost for health care requires that the entire cost for the US population is divided by the number of people in the population. That should be the percentage of GNP allocated to health care. There can be no profit in that for anyone without direct responsibility for delivering that care, though certainly various models for providing the care could compete for the available funds, as long as there is open participation, with no discrimination regarding the people covered in a model.
I sincerely hope my thanks for your consideration of our views are not wasted. I've become quite cynical about the entire political process, watching campaign accounts growing at the expense of a realistic assessment of what the country needs.
ESLMD
Small risks become major risks thanks to Senator A. Specter and his ilk!
Tort reform is needed desperately.
When the Democrats took over in the late 80's, they proceeded to dilute the existing law's power. They openly chastised the medical panel for ruling in favor of physicians, and they eased access to the pool money. The net result is that Indiana's terrific system in the 70's and early 80's is not nearly as effective as it once was. It is still better than any other state right now, but Indiana's experience should be instructive for everyone. Even when you get a good system in place, it requires continual vigilance to protect it. The Democrats and the trial lawyers tore down something that worked very well because they didn't want anyone else to adopt it!!
Thanks for asking our input. We already have socialized medicine in this country- Medicare and Tricare. We need RATIONING yes I used that word to keep a lid on the budget for those folks whose health care we are paying for. This needs to be done with some science and support and not be knee jerk- Oregon's system of allotting money in priority until it runs out is an idea. The UK's NICE is slow but official. Standards which could stand up in court- ie Medicare can no longer waste money on biopsies probably not needed, so the dermatologist is off the hook the 12/million cases when that was a mistake, would help and we need both specialist input and some fiscal supervision on that. Of course cardiologists will sleep better at night (and have more money) if every chest pain is cathed, dermatologists if every mole is biopsied, we family docs if everyone chats with their FP for an hour every three months. However we as a nation choose not to afford such thoroughness.
I have been a recipient and worker in the British NHS system, the US Army system, and still get my care through tricare on the economy. The Brits and the military families are better off than most Americans. I recently worked in an underserved underinsured rural area. I had folks dying to stay out of medical debt or because it was already such a burden on their families. The same reasons we have Medicare- it is obscene to let people die for want of money to pay for basic medical care- is true for those under 65. (You should hear how amazed and appalled British doctors are that we let Americans lose their home and their savings and go beg for pennies at the gas station or church if they get really sick.)
While you fiddle Senator ( you and your buddies on the hill ) Rome burns.
And yes a revolution is coming and many who would be as Senator Gracus said " I don't pretend to one of the people but one who is for the people" may be surprised.. the mob is fickle brother....look at the recent elections in VA and NJ
Look how quickly the GOP lost it's power by forgetting the principles of THE MAJORITY OF THIS COUNTRY!!!!
It's always a little too late and always a dollar short with yuall.....
We are not children
Senator and the vast majority of us are more intellingent than the " leaders of our country... what a joke...
To answer your question most of us spend our time practicing evidence based medicine already... we call it CME
How do " you" learn something new.... or is that really asking too much?
Abunch of old dogs doing the same old tricks only none of us find them amusing anymore....
I'll give you credit for bringing up tort reform and allowing us to sound off on the government trying to cram more crap dowm our thoats but some of us.. esp primary care could have used your help years ago when you and your crony's were cutting our wages..where were you then...
I'll bet you can't tell me how many docs went into Internal Medicine this last year....Senator Less than 200 That's right less than 4 per state..
Whose gonna take care your sorry $@$@#% when you get sick? a PA maybe some super bright NP?
Fix our reimbursement issues NOW!
Fix tort reform NOW!
Tell the rest of congress when they get an MD degree they can practice medicine.
We worked hard to acheive our expertise and we were not elected to practice medicine.....we earned the right.
Nuff said I'm outta here.
"Optometrists have very poor training beyond prescribing glasses and try to put every single patient in glasses whether they need them or not. There are millions of dollars in excess glasses each year that people don't even wear because they were not medically indicated. As California recently demonstrated, they are unable to manage glaucoma. If you want to cut down on costs, maybe you should start auditing chiropractor, NP, and optometrist claims first and see how much waste is there and see how much a royal mistake Congress made by ever granting them additional privileges."
I live in the DFW area of north Texas, Cornyn's home turf. As far as ophthalmologists go, they have made their own bed in increasing the business of optometrists. When cataract surgery was big time business, a person could not beg their way into an ophthalmologist's office for routine exam and refraction. They thought they were wasting their time. I know a retired ophthalmologist in town who sends his kids and grandkids to optometrists for routine exams for that very reason. I think that, as a group, ophthalmologists need to get their house in order before they go criticizing optometrists so freely.
And like it or not, when patients, make that clients, get used to getting fitted for glasses and contacts by optometrists, then they will be more inclined to seek care with these same providers for medical problems of the eye too.
Or you could just stay home and read Ayn Rand.
"Senator Cornyn:
The "questions" you asked are not valid. You're not at a rally of the same cowardly dim-witted yokels that you and your neo-con cronies terrified into voting for you and your ilk. The majority of the American people are smart enough to see through your lies. It's no longer just the few liberals that have been brave enough and patriotic enough to stand up to the likes of you for years. You've proven to be nothing more than an insurance cartel minion and Obama and Pelosi will bring you down."
Amen, amen, amen, amen..........
Answer only one but I need another study.
What is a radiologist"s favorite landscape?
The hedge..
All jesting a side just as the patholigists rendition of a path report goes on and on and on it is because if they put the complete diffential diagnosis they can't be sued..
Radiology is another example.....many times a simple nodule 7mm in a lung now becomes a CT every 3 months why.....?
Everyone here on this site knows why..
Real case
70 year old man with RA and chronic fibosis on xray of chest
Ct ordered to look for signs of RA lung
1 cm nodule LUL
BX positive for adenocarcinoma
Partial lobectomy
Cured right? N1T0M0
Dead 18 months later metastaic spread to chest wall..
The point? We are not God....
The Lawyers would like to portray us that we think we are......and make money off the suffering not only of the dead but of those who have given our lives to better the lives of those we serve... and yes it's not just a job it is a calling........
Back in the USSR
You don't know how lucky you are................ Senator
But when the old guard is gone...your newer docs are gonna check in and check out..
And you better hope your MI is during the first part of the year cause when you get to the office the sign might just say..................
GON FISHIN :-)
"And yes a revolution is coming and many who would be as Senator Gracus said " I don't pretend to one of the people but one who is for the people" may be surprised.. the mob is fickle brother....look at the recent elections in VA and NJ
Look how quickly the GOP lost it's power by forgetting the principles of THE MAJORITY OF THIS COUNTRY!!!!"
Hey, the Dem in VA was not a good candidate and did not run a good race. In fact, many Dem voters did not turn out because the candidate abandoned some Dem ideas that he should have campaigned on.
Hey, how about the far rightwing radical in upstate NY who Palin, Beck and her ilk tried to foist on the voters. They even forced the mainstream Repub. out of the race. And the Dem won in a district that has been R for a hundred years. You're right, a revolution is coming and it's going to throw out all the far rightwing teabagging, birthing, deathing, czaring, 9/12 ing fanatics that seem to have come out of the woodwork.
Thie rationing of care can be decided upon on a state and county level based on where they want to put those dollars. The feds need to stay out of the states' way wrt delivery of care models. California has a different demo than wyoming or Idaho. Give the states the greater say and allow guidelines to be just that.
Doctors are not allowed to practice medicine. We practice in a lot of instances defensively and access to and approval for studies impede that ability. The system needs change- I would challenge any industry, congress included to take a 25% pay cut and still remain in practice. It is rediculous to say that these issues are not intertwined.
The govt will effectively water down care and the bewildered public wont know the difference. They are not at fault. Insurers and physicians are to blame for that lack of insight. I always go out of my way to instruct what the consequences of treatment or lack there of is.
And don't forget the huge amount of for profit testing that is done and encouraged by the owners of big time medical equipment.
My parents came to the US not for a better life, but for the opportunity for a better life. When you kill the desire, want to excell you stifle creativitiy and entrepreneures who look for ways to re-invent the world. This is the social agenda that has been forced upon us. You are effectivley taking away our 'opportunity' for a better life.
Of course Washington will have our back when we are sued :(
But, it is time to get MAD! As David said, "When they get an MD, they can practice medicine."
The internet may prove to be valuable as a way of reaching and uniting physicians. Apparently, SOME Senators already see the benefit of asking a group of posting physicians for their opinions. However, I doubt that they have appreciated the answers they have received.
I think there is much more anger out there than they anticipated. And we ARE a representative group, just more vocal.
"The internet may prove to be valuable as a way of reaching and uniting physicians. Apparently, SOME Senators already see the benefit of asking a group of posting physicians for their opinions. However, I doubt that they have appreciated the answers they have received."
The internet is the opiate of the masses when it comes to Senators asking questions of a group of physicians. Have you gotten much help lately from Sen. Coburn who did this little exercise a couple of weeks ago? Do you suspect that Sen. Cornyn will be much different?
Of course I understand the patients position, better than signorrrrr...
I'm in the trenches treating them while they are awake...:-)
I'm just stating the obvious what's your point?
If you look out for lawyers, you will get more lawyers, and more legal actions. If you look out for doctors, you will get more doctors, and more access to health care. No set of "guidelines" will fix our seriously broken system, but if you allow the federal government to dictate (even more than they already do) how we practice medicine, it will become even more difficult for us as physicians to do our jobs.
Thank you - Mike Ford, MD
Thank you for your interest.
I believe that most physicians welcome data on comparative effectiveness, treatment guidelines, standards, and all the other "buzz words" of quality research, but only along with one specific caveat - that the data be offered for consideration as opposed to being mandatorily imposed.
Every practicing physician is aware that not all patients "fit the mold." Whether it is a child refractory to usual care for otitis media or a geriatric patient unresponsive to blood pressure medication, not all patients respond to treatments the same way. Imposing standards in such an environment can be disastrous. Thus, standards are a welcome occurrence within the concept of a "good first try", but mandatory standards are viewed negatively because we find that so often the good first try doesn't work, yet mandatory standards restrict our ability to proceed with alternative approaches.
The suspicion most physicians have towards government stems from the historically proven tendency of the government to become rigid in its approach to almost any problem, be it financial regulation, environmental protection or medicine. After an initial flurry of activity, govt tends to settle down to business as usual, while changes in the landscape cause the practitioners of the regulated profession to need alternative approaches. Yet govt remains inflexible until a crisis occurs, at which point there is another flurry of activity, new standards are implemented, and the cycle, over a course of years or decades, repeats itself. Along the way, however, much harm can occur.
Medicine is particularly vulnerable to govt regulation simply because it is such a complex yet dynamic undertaking. It is hopeless to consider that government has the ability to maintain currency throughout the field, when even highly specialized physicians of the most arcane and obtuse specialties find it difficult. Government mandates in medicine are doomed to fail, both in terms of effectiveness and, eventually, compliance.
Government's role in medicine should be to ensure that an equal level of opportunity exists for industry, providers and patients, but government cannot hope to achieve an equality of outcomes in any of those areas, which is the implied goal of mandatory regulation.
Contrary to popular opinion, physicians are not all avaricious louts whose sole concern is to squeeze money from the patients. While those poor examples may exist among us, even they recognize that the way to do well is to do good, and virtually every physician in the country really does have the patient's best interests at heart. Government regulation of specific medical techniques and practices, however, goes against that altruism.
Yet physicians are not totally altruistic. We do indeed fear malpractice, and many of the decisions we make daily are tainted by the desire to avoid the lottery effects of our current malpractice system. Given the extent to which legal advertising implies any negative outcome means a big money payoff, and the demonstrable effects of that mind set, our fears are fully justified, and we find it necessary to protect ourselves despite our altruistic tendencies.
In order for government guidelines to be most effective, they must be 1) voluntary and 2) linked to some sort of malpractice protection - treatment following guidelines should be protected from claims of malpractice. Adopting these principles allow the physician some protection from frivolous lawsuits resulting from standard care, while also allowing us the flexibility we need to exercise our expertise in ways the government is incapable of foreseeing.
Thank you for your attention.
"My question for you, and all of our elected officials is, do you want health care, or do you want the threat of lawsuits to make it unavailable? That may sound like both an extreme and a rhetorical question, but it is neither. There are areas around the country where OB care is not available at any price due to excessively high malpractice premiums having driven practitioners away, or out of OB practice altogether."
Mike, with all due respect, the medical profession has been saying this for decades already. Medical care has not dried up and gone away. Sure, no one wants to get sued. Sure premiums are high for many specialties (has anyone ever looked into how much insurance companies charge vs. how much they pay out in claims?). But the "malpractice crisis" is not at some new boiling point now. This is just not the main problem with healthcare at the present.
And the GOP "solution" seems to consist of mainly of a couple of things right now. One is the tort reform you are seeking Mike, and the other is this corny idea of buying insurance across state lines. Does anyone really think that I will suddenly be able to get a great deal on health insurance because I can buy it through a company in Idaho as opposed to having to shop only plans that are available to me currently in Texas where I live? How in the world could these two things result in any kind of meaningful answer to the health care problems facing the U.S.?
The value of the internet here is that doctors can communicate on these issues with each other. Doing it anonymously is also helpful, I believe. In my particular case, my vocality on matters of policy and quality assurance, have caused me to have some enemies in the profession. I am not upset about it, because these are people I would not want as friends, and neither would you.
Nevertheless, it is useful to be able to speak out purposefully on contentious issues instead of burying them and pretending they don't exist, which is what our profession has done historically.
Time may be ripe for healthcare reform simultaneous and parallel with the legal reform in an ideal combination.
I am a cataract surgeon. The worst complication that can occur following routine cataract surgery is infection, which can lead to blindness. There is very little scientific evidence in support of the various measures we use to reduce the risk of infection following cataract surgery, and in fact that most efficacious measure, based on the evidence which is available, is the also the least expensive - the sterile prep and drape done right before the actual surgery. I mentioned that fact to a drug rep whose company makes one of the expensive antibiotic eye drops we routinely prescribe for patients after cataract surgery, and he immediately pointed out that if I were to stop using it I would be likely to be sued for malpractice if one of my patients were to get an infection following cataract surgery, whether or not there is enough evidence to prove that the drop reduces the risk of infection, simply because most other cataract surgeons use it.
I'm sure you see my point - drug companies love it when doctors practice defensive medicine! Of course their products are not free, so defensive medicine costs money, and malpractice reform is essential to controlling health care costs. Without it we will continue to be "encouraged", no, actually "strong-armed" into doing things we know to be unproven, just because as that drug rep said to me "all of your colleagues are doing it, so it must be the standard of care". Who among us wants to step "out of line" and risk being sued, when the system fails to protect us against ridiculous claims which have no basis in scientific fact?
Again, no guidelines can fix this problem. We need tort reform!
Thanks for reading - Mike Ford, MD
And Midrin is just one of many older medicines being cancelled by the FDA. The other step badly needed is to absolutely ban advertising of prescription medicines. The drug companies complain that new medicines cost so much because of R&D. Yet many of the companies spend at least as much on advertising as the do on R&D.
More and more laws, in the form of rules, regulations, and policy pronouncements,are made by administrative agents and CZARS. These are outside of the open and transparent requirements of responsible government, and without congressional approval and oversight. This is beyond the principle that legitimate government arises out of the consent of the governed, i.e., no representation of or by the PEOPLE.
The more government regularly operates as a matter of course outside of popular consent, the more we become clients rather than rulers of a vast government, the less we are self-governing, the less we control our own fate, and the less our elected representatives have to say about our political future..
As Alexis de Tocqueville warned in 'Democracy in America', this is the recipe for a benign form of despotism that truly imperils our democratic experiment. Now, the chaos of our economy has presented a new opportunity for the WH to create a grand Socialist system of Govt. to control all aspects of our lives.
Comparative effectiveness research has, for some reason, attracted the ire of physicians as a tool for rationing. However, it is a limited tool that will give us some data about what drugs work where, and for what types of people - things we don't know now. When I did primary care, it was nice to know that a solo Ace inhibitor wasn't likely to be the best drug for African American patients as a first line drug, but that combining it with a thiazide diuretic would give me the best first line odds of control.
The draconian restriction on theraputics and drugs is unlikely to occurr for the following reason: a) Americans won't put up with it, b) it isnt' an effective way of doing business. Now, if you are doing procedures that turn out to be not better than sham (say, a orthoscopic knee "clean out", or chiropractics), then you have reason to worry that you'll be denied payment by the government. However, it doesn't mean that, just because you sell snake oil that you can't charge cash and stay in business (just go to GNC and see for yourself, snake oil is alive and well); just don't expect the rest of us to foot the bill.
As a sidenote, I do some comparative effectivenss research as part of my work, and do have grants out currently for more. However, most of the work I do is in comparing routes of delivery, methods of delivery of drugs, along with patient outcomes. Our aim is to provide practitioners with information to make informed choices at the bedside with patients - and we write our papers that way. Now, not all of our work is popular (ie if we find a therapy is actually harming patients or a subgroup of patients is the only group that benefits, etc), as we recommend not doing that anymore - or at least changing the way that we deliver that therapy (ie. pediatric lung transplant for CF) or futher study.
I didn't do the survey so I guess I missed the tort reform questions. Indiana's model is the model that should be applied nationwide - a panel of three physicians reviewing the case prior to trial, and the recommendations of that panel are admissable in court... and the panel is required prior to trial. Malpractice costs and costs of care are low in Indiana. If the Republican party was interested in getting anything done on tort reform, they could this year. The Democrats are interested in looking bipartisan, and would be willing to fold in tort reform to a bill if the Rs would vote for it... but it won't happen because no one in Washington wants to look like they compromised on anything. Too bad for America that we've become so rigid and inflexible.
As for protocolized care talking over your life - it will actually make it easier in that standards are published. If you think that a patient won't benefit from (or if they fail) standarard therapy you won't have a beaurocrat hanging over your shoulder...
As a young physician who is frequently at the hospital late with patients in the ICU, I can tell the old geezers complaining about us young folks abandoning patients to stick it where the sun don't shine. I get tired of hearing senior physicians complain about us not working when I'm putting in 100+ and they are doing 60. I'd say I'm sorry but I'm not.
DORF: Doctors Office Relief Program. :-)
And a Big " Thanks and Amen" to you, Dr. Sermo Doc 25!
My biggest concern is that the fear of being sued leads many of us to "go with the pack" when making treatment decisions, rather than trusting our own education and experience as well as the peer-reviewed literature to guide us. There is also an awful lot of off-label drug use promotion by drug reps, who sometimes will stoop so low as imply that the standard of care in a given situation is defined not by any scientific evidence, but by what they have been able to convince most doctors to do.
The very existence of the medical profession may not hinge on malpractice reform, but effective cost control certainly does.
Mike Ford, MD
The AMA does NOT represent me, nor the majority of Physicians in this country. They are a self-serving organization whose purpose has become to make money through their exclusive monopolies on the use of billing codes and RBRVS.
The government health care reform, as proposed, will do to medicine what the government's involvement has done with the post office, social security, Medicare, Medicaid, public education, etc... I cannot think of one thing the government has done better than the private sector, and plenty of situations where it has driven them into the ground. Why should I think they can improve on health care financing?
If you want to fix the economy, leave health care alone, loosen up red tape and taxes on small businesses (I run one, and it gets more difficult and expensive every year), and support all, I mean ALL measures to investigate, audit, and eventually SHUT DOWN the FEDERAL RESERVE BANK! This, Dear Senator, is the meat of the issues facing our economy. They are a private group of wealthy bakers that run Wall Street, our Department of Treasury, and are in charge of monetary policy and money supply, and through their artificial manipulations of money supply, have mangaged to STEAL America blind! They profit, repeatedly, from our losses.
End the Fed and many, many of our problems will resolve, through allowing the free market to control our economy. Remove artificially imposed barriers on the free market, and give our money some real value by, once again, limiting the supply and backing it with hard assetts. If it doesn't occur, we are all screwed.
James Landers, MD
That settles it. The AMA is now officially the enemy of real practicing doctors in this country. No organization that truly represents physicians can endorse ANY reform legislation that does not contain MEANINGFUL tort reform, period! That IS and will continue to be, the acid test.
Cornyn the Barbarian! Thanks for gracing Sermo with your presence.
Can your survey be any more biased and leading in its questioning?!?
All you need now is a link to donate money to the GOP after instilling the fear of government takeover into the trembling right wing docs on Sermo. "
Please. At least the GOP is representing physician interests. If you ever got your head out of Obama's posterior, you'd realize that he doesn't give two sh*ts about physicians as a profession, and is more interested in scoring political points than actually improving healthcare in this country. He'd much rather protect the trial bar.
Expanding an underfunded/nonfunded entitlement without substantial increases in revenue or decreases in costs results in no deficits in which alternate universe?
2. Tort reform is a no-brainer. PriceWaterhouseCoopers (2008) estimated it at 10% of total HC costs, i.e. 200 billion. You could cover all the poor with this amount of money.
Yea that's the "mainstream" republican who endorsed the democrat - I thought you were supposed to be a physician to comment here. This quote comes straight from David Axelrod's talking points. Calling that nerdy accountant who needs to see one of the Ophthalmologists posting on this thread immediately for strabismus surgery a "far rightwing radical" is hilarious.
In the past Comparative Effectiveness Research (CER) was the province of a small cadre of scientists and policy analysts. CER is not new: the Agency for Health Care Research and Quality (AHRQ) has funded some 28 centers which have produced a wealth of evidence-based data on the cost effectiveness and efficacy of drugs, medical devices and procedures used in the treatment of various disease states. On 17 February 2009 President Obama signed the American Recovery and Reinvestment Act of 2009, which allocated $1.1 bn for CER studies that directly compare the risks and benefits of different treatments for a particular condition and are essential for improving care and controlling escalating costs. [1] The act also mandated the Institute of Medicine to recommend "national priorities for comparative effectiveness research." [2, 3] It established a Federal Coordinating Council for Comparative Effectiveness Research whose task it is to recommend and to coordinate such research but will not be able to establish clinical guidelines or to "mandate coverage, reimbursement, or other policies for any public or private payer." [4]
CER is the mode to identify the method of treatment which is most effective for an individual patient under specific circumstances. It is anticipated that CER will yield greater value for the US healthcare system and better patient outcomes. [5, 6] The best definition is seen in the IOM brief: "CER is the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care. The purpose of CER is to assist consumers, clinicians, purchasers, and policy makers to make informed decisions that will improve health care at both the individual and population levels."
It is intuitive that such methodology is necessary to improve care and to control cost for all patients. Unfortunately, this has generated a coterie of interest groups asserting, despite evidence to the contrary, that CER will have a dampening effect on personalized medicine. [7, 8] Other nescient opponents—especially certain Republicans and their ilk—has expressed concerns, totally without any substantiation, that CER findings could lead to rationing and government intrusion into the doctor-patient relationship. [9]
CER enables both healthcare providers and consumers to make better informed choices, thereby, improving the quality of healthcare services and reducing healthcare costs. The aspiration to provide better and more cost-effective healthcare through the application of CER is shared by the US Cochrane Center and by enlightened stakeholders throughout this country. The question to be answered is will CER guide clinicians into adding the knowledge base to and making appropriate changes in their daily practice of medicine. [10, 11, 12, 13, 14, 15]
References
1. The American Recovery and Reinvestment Act of 2009 (accessed at
(http://thomas.loc.gov)
2. Institute of Medicine, "Initial National Priorities For Comparative Effectiveness
Research," Report Brief, June 2009
3. Iglehart, JK, "Prioritizing Comparative-Effectiveness Research—IOM
Recommendations," NEJM 2009; 361(4):325-7
4. Conway, PH, et al., "Comparative-Effectiveness Research—Implications of the
Federal Coordinating Council's Report," NEJM; Online First, 30 June 2009:
10.1056/nejmp0905631
5. Kuehn, BM, "Institute of Medicine Outlines Priorities for Comparative Effectiveness
Research," JAMA 2009; 302:936-7
6. CBO, "Research on the Comparative Effectiveness of Medical Treatments: Issues
and Options for an Expanded Federal Role," December 2007
7. Garber, AM, "Does Comparative-Effectiveness Research Threaten Personalized
Medicine?" NEJM 2009; 360(19):1925-7
8. Volpp, KG, "Comparative Effectiveness—Thinking beyond Medication A versus
Medication B," NEJM 2009; 361(4):331-3
9. Avorn, J, "Debate about Funding Comparative-Effectiveness Research," NEJM 2009;
360(19):1927-9
10. Alexander, GC, "Does Comparative Effectiveness Have a Comparative Edge?"
NEJM 2009; 301(23):2488-90
11. Brook, RH, "Possible Outcomes of Comparative Effectiveness Research," NEJM
2009;302(2):194-5
12. Editors, "Ensuring Integrity in Comparative Effectiveness Research: Accentuate the
Negative,"PLoS Medicine 2009; 6(9):e1000152
13. Kaiser Family Foundation, "Explaining Health Reform: What is Comparative
Effectiveness Research," October 2009
14. Naik, AD, "The Neglected Purpose of Comparative-Effectiveness Research,"
NEJM 2009; 360(19):1929-31
15. Wechsler, J, "Comparative Effectiveness Research to Shape Biotech Studies,"
BioPharm International 2009; 22(5):18-19
Our bowl of rice hangs in the balance. Leave alone the dollars and cents issue. What is right for the patient will become secondary.
The "left wing" stance ala Pelosi / Reid / Obama et.al. will lead to a cast system of haves and have nots. Free market capitalism where the monopolistic insurance giants lose their anti trust protection is the one feature I agree on within their current 2000 page proposal. If the annual premiums drop precipitously, the whole system would benefit.
As one of your constituents I again urge you to consider the logic that individual choice is fundamental to competition and real change. Reshuffling the deck of insurance, employer, and government interests alone does not make things inherently different. I find it completely illogical to say that we must save/increase Medicare (a government [poorly] run program) from one side of the mouth, while from the other saying NO to a government run program. Have we learned nothing from Madoff?
Our veterans from the greatest generation (and now the boomers) have been thrown to the VHA (not a shining example of government run healthcare) or stuck with TriCare only to be kicked out to Medicare when they reach age 65 years. We know this will happen.
Finally, health care is not a right, nor should it be mandated by law to carry. In fact, health "insurance" is largely only a pre-payment agreement, most of the money from which gains employers tax breaks and is not used by patients (does not accrue or roll over like HSAs) when young and relatively healthy -- too much insurance!
Divorce health care decisions from peoples' employers, give us tax breaks to use that money the way we see fit, and stand up for us physicians when the President tries to demonize us in front of the American people!
Thanks for your support
If there was no tea party in Colonial Boston and no Revolution, we'd all be working for the UK National Health System and still drinking their tea...or is it KOOLAID now???
By the way, in 1776 there was no GOP, which was the party of Lincoln (a big favorite of Obama).
Thankyou for your request for input directly from the physician community. Although there are many viewpoints here, many many of us are deeply concerned about the direction that the healthcare reform bills in the House and Senate will take us. The AMA's endorsement of H.R. 3962 just does not represent American physicians at large with their membership at less than 20% and falling.
Healthcare is complex and there are many issues in addition to the two you mention:
Medical Liability Reform - This is a must. The Texas experience illustrates the increased physican supply that resulted after your states reforms were put into place. Amazingly Pelosi's bill not only provides NO medical tort reform but would punish states like Texas that do. THIS IS EXACTLY THE WRONG THING TO DO. Out of control malpractice insurance drive physicians out of practice with ruinous effects on access to basic services - especially obstetrics. Add the expense of Defensive medicine and the status quo is untenable.
Competitive Effectiveness Research - certainly has a role in healthcare - but should NOT be an arm of the Federal Government where it has the potential to be used for rationing and denial of care - even when the treatments have been proven safe and effective. Please don't let "Health Benefits Advisory Commission" be allowed to cut off effective treatments to our citizens like the U.K.'s NHS has done with treatments like Herceptin for Breast Cancer.
The private medical sector has provided leadership in application of safe and effective treatments. The Anesthesia Patient Safety Foundation is a prime example of this.
We need more Competitive Effectiveness Data and Research, but the government should not be the entity entrusted with applying this information to medical decisions. That should be left to physicians and patients. Pay for performance measure could be used to carefully encourage appropriate treatements, BUT outcomes and treatments need to be chosen VERY CAREFULLY and only applied when there is OVERWHELMING evidence for or against certain treatments. This process should never be rushed or politicized. Even though pay for performance efforts have just started they are already misguided in many cases - for example some of the "never events" recently imposed by the HHS. These are events that are to "never happen" and thus are not re-imbursable. Some make sense like and some absolutely don't.
online.wsj.com
Unbelievably, in the worst recession since the great depression, the HR 3962 places new onerous tax burdens on employers, medical device makers, and the "wealthy". Can we really afford this bill? I think not. We have a deficit of $3 Trillion over the first 2 years of this Democratic President's Administration! Yet we celebrate this bill shaving a MEASLY $34 billion off the deficit in 10 years. Just last week the estimate was $88 billion in savings. Given the history of massive cost underestimates in government's involvement in healthcare, I doubt any of these savings will ever materialize....EVER!
The bill states that the public option will never receive federal funds in case of insolvency. This is disingenuous at best given the recent history of our bailout nation including Fannie Mae and Freddie Mac that have added trillions in unrecognized liabilities to our nation's balance sheet. A bankrupt public option will most certainly fall under the auspices of "too big to fail" and will most certainly receive public funds if this eventuality is ever realized.
Instead of this massive expansion of government entitlements and potential liabilities we should be embracing free market reforms, encouraging individual responsibility, encouraging increased supply of qualified physician and healthcare provider labor, strengthening the healthcare safety net, and finally rewarding efficiency, productivity and most importantly continued innovation - not stifling it with higher taxes and suffocating regulation.
Healthcare reform is clearly needed, but more than anything American needs health insurance reform, not a massive new government entitlement program.
Increase competition by dropping the anti-trust protections that these companies enjoy and allow insurance to be bought and sold over state lines. Neither of these provisions is in the current bill. Require all insurance companies to accept patients regardless of pre-existing conditions. No lifetime cap on benefits should exist. We have all seen relatives and friends that are denied coverage when they need it most. WE NEED TO CHANGE THIS.
Insurance should be uncoupled from the workplace and individuals should not be penalized just because they don't get their policies from their employers; an individual mandate to buy insurance with vouchers for the poor to buy their own policies in the private market should be adopted - much like food stamps allow recipients to shop at the markets of their choice. Government should rightly provide a safety net by helping those who are indigent and underserved. We need to strengthen this safety net but a new massive government entitlement will only make healthcare worse - not better.
An individual mandate should be in place with penalties high enough to avoid "gaming the system" like that which was seen with Maine's failing Dirigo plan and is being seen in Massachusetts now. Policies should be high deductible with HSA-like accounts that allow consumers some "skin in the game". HSA contributions should be tax-deductible and if not fully spent applied to higher educational expenses for family members or eventually become a supplemental retirement account (like a 529 or a Roth IRA). This provides both required health savings and an incentive to reduce utilization. I don't see anything like this in HR 3962
Patients must be responsible for their health. If basic healthcare is a right then it is also a responsibility. What basic risk factors can be modified should be modified. After reasonable "grace periods", insurance companies should be able to increase premiums when improvements in risk factors deemed modifiable by a patient's physician are not attained. This is not unlike auto insurance and provides a mechanism to incent lower utilization through decreased risk. This need not be complicated or intrusive. Simple efforts in the areas of smoking, cardiovascular health, and obesity/diabetes prevention are already yielding tangible benefits in private companies. Individual choice remains intact and allows individuals to choose a higher-risk lifestyle if they so choose; lifestyle choices with risks and costs that individuals alone are burdened with and not society as a whole as the system now allows.
Market based solutions are working now within private companies with great success:
online.wsj.com
online.wsj.com
www.businessweek.com
Enacting HR 3962, physician supply will dwindle in the form of quality hospitals and providers. Wait times will increase. Healthcare will become an electoral issue every political cycle as it is with our socialized allies Canada, Europe, and Japan. Quality will suffer. People will suffer.
Today, graduating physicians are burdened by hundreds of thousands of dollars debt from their medical training and struggle to pay this debt every month. The bill as currently written will eventually result in government price controls and decreased physician incomes. This along with unchecked medical education debt will severely decrease physician supply just when the baby boomer demographics demand more medical care than ever. This will inevitably result in decreased quality and increased delays for the care that our citizens need. Any healthcare reform need to redress these issues. But amazingly there are no provisions in current bills that addresses maintaining adequate physician supply.
Our Forefathers designed a system of government that has worked for generations because of their insight and wisdom; designing the perfect system of checks and balances, individual rights, and the balancing the Federal and State systems. It was and continues to be a miracle. It simply works. Our political system was unique, designed in the midst of failed, unjust, and cruel regimes the world over. It was the innovativeness, the uniqueness, and the justice of the system that has made it the model for the rest of the world.
Just as America led the way in creating an unparalleled political system, it is time that we do so again by creating a truly unique, innovative, and fair healthcare system that is American in nature and will become the model the world will follow and not simply a copy-cat system of European-style government-run healthcare.
Healthcare is too important, too personal to relegate to a "government program" - our citizens deserve better than the rationing of the socialized systems of our European and Canadian allies which will be the ultimate result of a public option. An option that will eventually crush private competition, imploding into government-run single-payer system that mandates who can have what care and for what price. We are Americans - we can do better - we expect better and we deserve better.
I disagree with many of the above postings with regard to comparative effectiveness research. WE NEED IT. There is tremendous waste in medicine, both from defensive medicine and from overuse of treatments of questionable benefit, often with large price tags. As a taxpayer and health insurance purchaser, I hate that my taxes and premiums are wasted in such a fashion. Malpractice reform + increased comparative effectiveness reseach = reduced costs and probably better care. Sermo Doc 97 laid out the history and case for comparative effectiveness research well. The losers would be pharmaceutical and device companies who spend more on marketing than R & D.
I know that we docs could not possibly be as cleaver as you.
But, dang, as dumb as I am, I know that the question you ask is talking down to us.
You are a work of art, just like Damien Hirst's Hundred Years, a large glass case containing maggots and flies feeding off a rotting cow's head.
And Sermo, wow, you are clearly interested in our input(as long as you can slant it your way!!)
Some of us care about U.S. medicine and our patients.
This sort of thing seems to be one more step in "guidelines" too often becoming "laws".
Maybe the government should be responsible for paying all malpractice claims.
I bet you would see cost controls then.
Malpractice as an industry resembles kidnapping-only difference is its "legal"
The greatest engine of unfairness is the legal system.
The vaccine manufacturers have statutory protection from suits.
The drug companies have statutory protection from lawsuits.
Why not physicians?
P.S. M. Bachmann did not appear to notice that her man Boehner was reciting the wrong lines.
Defensive medicine is real and costly. Fear of litigation is high and growing given the ever mounting "jackpot" awards for pain and suffering. Patients have numerous imaging and laboratory tests performed just for fear of missing a rare diagnosis.
Tort reform is urgently needed. most lawsuits are frivolous. doctors always lose even if they win when you assess the emotional and financial toll of the lawsuits. we need to punish lawyers who take on frivolous suits, use screening experts to deem whether cases are meritorious and perhaps have the loser pay the legal fees.
comparative effectiveness is not useful. clinical problems as they pertain to an individual are complex and do not lend themselves to a simple forumla. this task should be undertaken by medical societies who understand it better.
That said, I feel if there is to be any sort of tax supported option - and I feel there should be - then there is a requirement of some type of rationing. There must be or it will be financially impossible. Does this mean there needs to be "death panels"? Does this mean someone has to stand up and say which patients are more beneficial to society and deserve to be treated? No. But it does say there needs to be a way to avoid frivolous care - like the multiple Medicaid recipients who go to the ER for their colds because it's "free" and then they can get a prescription for ibuprofen and robitussin and then it will be "free" as well - as well provide good, evidence based, patient centered care when needed rather than getting a CT for every headache due to the fear of the one in a million brain tumor that might be missed and cost someone their career.
I feel all publicly insured patients - Medicare, Medicaid, and any new program that comes down the pike - should be treated first in a residency setting. I believe residencies should be our nationwide "free clinic". They are already funded extensively under the Medicare budget. Most are in non-profit institutions. It will provide exposure for all our up and coming physicians to the tribulations of other Americans who are not so fortunate to be able to go to med school. It will also provide access to care for that population when so many private physicians are turning them away. If there aren't enough available appointment slots in the residencies, then expand them. Plus make it an option for graduates to continue working there after residency to shoulder part of the load in exchange for loan repayment.
I could ramble on forever and have many more Ideas, but I doubt many of you have read this far already, and certainly not our esteemed surveyor or his staff, so I will end here. Respectfully, Jim Yerger, Family Physician
if we're going to have a Socialist Health Care Plan run by the BOmarx Govt., then let it pay "all malpractice claims" as you said!
The only problem, there won't be many Doctors left in the U.S. to sue (except for a few Socialist cynics here on SERMO) ! LOL!
POTUS does NOT care about doctors... or really about maintaining the highest quality of medicine possible. He cares about insuring/providing insurance for the 10's of millions of uninsured, and providing some sort of mechanism so that if you become ill, you will not be driven into bankruptcy.... The neo-cons on this site are all whining about him being evil etc.. nonsense... his concerns are with others,, most of whom far less fortunate than most of us! Get over it.
If government got out of health care, we would be almost immediately back to the 1950's where one illness bankrupted an entire family. 50 years ago, we did not have that many MRI's, CT-guided biopsies and broad spectrum antibiotics and chemo... You LUDDITES who keep insisting to return to the "good" old days with no dialysis, no CABG's or stents etcs.. are so blindly wrong..it is nauseating.
As long as the government shields people from the costs of their care, there will be an UNENDING stream of demanding patients insisting that "everything be done for dear old dad." Rationing through best practices policies is the only way to control cost in that scenario... Otherwise, if you make people pay for part of their care,,, no more chemo, PET's, hip replacements for those older than 65 etc...
The poll above is insultingly Right Wing Fascist Fox crap, and I did not answer it's pseudo-questions.
The health care changes will not be as drastic as so many of you fear right away as many docs are employed and there situation will not change... and many others have families, kids in school and cannot just drop medicine...
CER is obligatory if this country is going to control costs... but its results should be guidelines and should help us defend ourselves in case of a lawsuit.
Haystack, Macleod and Sermo Doc 83 all have some excellent cogent comments.
That the AMA can support health care reform without any national attempts at tort control should show every American Physician where we stand in their eyes..
The ACP, AAP, ACS and AAFP which together represent a whole lot of docs, have not said anything yet... I wonder..
The calls by some for revolution etc... keep it to yourself..
We all know of worst case scenarios... we are not even in the same galaxy
as those kind of extreme options.
I fear that talking mouths like Sen Cornyn don't really give a c#$$@ about us and are just politicking.. I really doubt anyone in power reads any of this...
If we don't form a union or have some meaningful political power, we are all really just wasting our time on issues like this...
Better to go back to interesting medical cases ...
You are right about the excessive sales of glasses and the poor training of many optometrists.
I believe that medicare part B should pay ONLY MD's and DO's and probably oral surgeons and podiatrists.... Not optometrists, and not NP's and certainly not chiropractors!
On the other hand, I object with being lumped in with optometrists in the way you suggest.
I am so busy taking care of MediCal patients who need medical and surgical eye care that I simply can't take my time to provide glasses and contact lens exams. There are 2X more optometrists in this country and they SHOULD be providing this service.
In California, I can not allow my technicians, opticians (if I had one) to perform refractions...its against the law. That is so stupid I can't even describe it...so I would have to take my time to do that exam, vs spend the time taking care of diabetic retinopathy, cataracts, etc....
I do NOT participate in kickback arrangements with optometrists either (and thus lose a lot of business) but I sleep well at night about that issue.
You ARE so correct about the money wasted by people who are sold way too many glasses.....but this is not part of medicare or mediCal anymore (neither are optometry exams part of CA Medicaid anymore...which is correct as far as I can determine)...
I ask my pts if they see well with their current glasses. If they say YES and I can verify this on exam...why would they need new glasses??? Unless they are damaged or the pt is financially able and desires a new style...I tell them to save the money.
Comments?
I was making the points about ophthalmologists being too busy to want to fool with routine eye exams and refractions. I was making the point that this is why so many patients are turning to optometrists who are providing a much needed service. I was also making the point that these patients will likely stay with their optometrists for medical eye care, for better or for worse, simply because they have established a relationship with them due to the fact that the overly busy ophthalmologists could not make time for them in the beginning to refract them.
This kind of enquiry is quite insulting to our intelligence and a waste of our time. Many of my colleagues have put up very elegant and cerebral answers, not just repartees. I also see some of the posts have references. The least you could do was prove that you are serious about this and join the discussion.
This is a worrying that senators are allowed to put up posts which serve only to inflame. Let us not have any more threads from them UNLESS they particiapate in the thread.
Why waste time posting very intelligent, lengthy, educated and well documented Posts if they're not being read or considered?
It's like spitting in the wind?!!
I am strongly in favor of a socialized health care system in America. We absolutely need it. I support a hybrid system similar to Italy, where there are both privately owned and public hospitals, but where the government subsidizes or completely pays for both sides. Such a system ensures competetiveness between private and public sides, and generally ensures good care on both sides.
I hate that we scorn the word "rationing", like it is something bad. We have a limited amount of money to spend on health care, and it must be apportioned in some way. Each individual patient wants everything possible done to maximize their potential outcome, and each doctor wants to do everything for their patient. Unfortunately, those two truths add up to unlimited cost health care. There must be a third party of unbiased experts who come up with some reasonable limits on what will be provided. Insurance companies already do this, all the time. They use Anthem and Milliman guidelines to decide what is and is not "medically necessary", and often don't pay for something that is out of guideline, even on appeal. So rationing is nothing new. The country just doesn't realize it.
Tort reform is an absolute necessity. There is no question that health care is made much more expensive by defensive medicine. Just today I ordered a breast ultrasound on young woman that I am 99.9% sure has no problem, just to quell her concern over a benign finding in her breast. I wasn't really thinking about liability when I ordered it, but liability has created a general mentality that we must search to all ends to find any disease, no matter how slight the possibility. The system has lost sight of the fact that doctors are there to improve health and to the best of our ability detect and treat disease. We are not the causes of the disease. There is something fundamentally wrong with the idea that we are liable for the death of a patient from a natural process, just because in some iteration of reality we might have caught it if we had made a different choice. We only live once; we don't get a chance to take it back if we make the wrong choice. Who holds anyone to a standard of always making the right choice? Its ridiculous. Its like we are responsible for every alternate reality that emanates from this moment, yet we only get to live one of them. It more than double jeopardy, its like jeopardy ad-infinitum.
I hope you get a chance to read this, as it differs from the majority of comments you will see above.
Thanks
Nicholas Fogelson, MD
1. government needs to be a referee not a player in health care. i agree for need to imporve balance of power between health insurance companies who makes all the rules and decisions now and patients and docs. level the playing field. End anti trust exemptions- break up the big insurers Well point , united heathcare into smaller competitors- just like Standard oil and Bell in the past. Make them compete on service and price . Allow inusrance to be sold across state lines. Allow doctors,pateints and employers to cllectively bargain on price and fees Have standard efficient billing and payment rules for all payers - based on AMA CPT guidelines currently in place . Medical necessity to be determined by an Independent ( not government appointed ) panel - see #2 below
2. Have independent multidisciplanary panels (IMDP's)
of all the stakeholders- funded by government and insurance profits to determine "comparitive effectiveness" and set up "Best practice guidelines".Many of the guidelines already exist for many clinical problems as noted in the Medical Literature. ie North American Spine Society guidleines These guidelines will not determine payment if reasonable alternatives are available or it data is lacking . Only recommendations with overwhelming Grade A evidence with no reasonable alternatives will be allowed to determine payment ( i.e. appendectomy for ruptured appednix, surgery for broken hip ) The majority of the panelist's should be physicians with subcommittees for each specialty- the doctors on the panel will be selected by each specialty organization like American College of Surgeons etc. . Patient advocates , Insurance representatives, Government reps, pharmacutical and med device reps , Epidemiologists and Economists all have a seat on the panel but doctors should have the majority of votes. Doctors are in the best position to know what is best for patients. These panels dictate the rules to all insurance payers. If reasonable (not excessive) documentation is appropriate, then the treatment is paid promptly ,electronically within 30 days -period. this will simply the billing /collection process and eventually decrease doctors overhead and allow us to reduce fees and costs
3. Med malpractice reform is essential!!!!- having visited hosptial and doctors in Germany and speaking with physicianswhove trained or work in Canada, England . France, the biggest difference between our health systems and theirs is the lack of defensive medicine and lawsuits. their charts are smaller, doctors and nurses spend less time documenting care and more time providing it!!!. - We need a
"Loser pays" system where plaintiffs attorneys have to risk compensating wrongly accused doctors to force them to make sure they take on only cases with merit. Merit panels made up of physicians in the same specialty as the accused would determine which cases deserve payment and streamline the process. this is done in Germany Most patients with legitimate injuries due to malpractice are offered immediate settlement which reduces costs for all. it is the greedy trial lawyers (both plaintiff and defense) plus expert witnesses and transcribers etc who benefit most from the current system
'thank you sir for listening
william barrick md
wow, could those survey questions have been more biased?
Comparative effectiveness information doesn't have to go hand in hand with "one size fits all" dear Senator. It will go a long way in reducing the amount spent on Z-packs for bronchitis though.
For example, one doctor may have lots of hospital admits for people with a particiular problem because he is ineffective at controlling the problem, resulting in hospitalization, while another doctor may have a large practice of these types of patients, and others send them to him because of his skill. In this case, the skilled guy may get so many trainwrecks he looks like the bad one.
Doing this type of research to a reasonable standard of certainty can be very expensive. Then MDs become liable for knowing what this standards or research was. Finally, the bureacracy will then enforce that this is the only way to manage the patient even when common sense says you should do something difference.
The best example of the problems of this research is the current pharmaceutical system which requires a certain diagnostic code for approval of a certain pharmaceutical. This essentially results in people who obviously would benefit from a certain drug, dying or suffering because the payor decides that its not the write diagnosis and the drug is "not medically necessary."
Comparative effectiveness research certainly could decide when surgery is appropriate, although with same caveats.
We already have these types of systems implemented and they do not work well.
I just finished a section of the FP Boards. It is called a Self Assessment Module and can be done as a group exercise with other FPs. We reviewed th evidence for a number of cardiology interventions. There are some interventions (meds, imaging, procedures) which have little evidence that they actually improve lives. I WANT that data in my hands so I have resources to explain to someone why a particular med or xray or procedure isn't in their best interest. Of course those companies which market the med or the CT scanner or the new device will fight this. I hope your motivation for the question is not triggered by a lobbyist or large contributor.
also in 1965 it was predicted that Medicare would run out of money in 25 years.. and in 1990 it DID... WE DOCS were accused of causing the problem and Hi technology altho in TRUTH we had remarkably DECREASED MEDICAL COSTS in ASTHMA care and COPD care by cutting out major hospitalizations.. I trained at one of the Premier Respiratory Hospitals.. and the AUDACITY of a LYING GOVERNMENT to BLAME US for WHAT WAS clearly THE FAULT OF THE Corrupt President and party IS A PROBLEM.. YOU CAN NOT LET THEM CONT TO BLAME US! the Democrats have repeatedly CAUSED problems and then BLAME everyone else... just as in the HOUSING MESS... MY Husband was forced to sit and listen to ATTORNEY G Janet RENO and SEC TREAS of P. CLINTON force the banks to GIVE LOANS to hi risk people who NEVER paid any of their bills on time >>"OR BE LABELED RACIST!! "
even NOW, HOW many first time home owners have a clue about the massive property TAX escalation everywhere........... and so this will just repeat the disaster!
Republicans NEED TO STAND UP TO THE SICK DEMS AND FIGHT FIRE WITH FIRE! You can maintain standards and still fight for a REAL America! that will become again "THE HOME OF the FREE and the BRAVE!":
My understanding is that Sermo charges a fairly hefty fee for nonmember entities to ask questions of Sermo physicians.
Just curious: Does Cornyn get a free ride because he's a member of Congress?
If so, does that mean that Sermo is now an open forum for any politician who wants to make a stump speech in the guise of "polling the physician community"?
If not, then who is paying the bill? Taxpayer dollars? Cornyn himself? His re-election fund? Political action committee?
Has anyone wondered about this? Feel free to offer some transparency here, Dr. Palestrant and Sen Cornyn...
In "The Jones Plan: a Reality-Based Approach to Healthcare Reform (http://jonesplan.blogspot.com) I recommend an "American Health Quality and Education System," or AHQES (similar to the system proposed by Dr. Guy Clifton [11]). The AHQES would be a federally funded, non-partisan agency with the mission to:
a. Systematically evaluate and publish the effectiveness and risks of all treatments and diagnostic tests.
b. Systematically evaluate and publish quality measures for all healthcare providers (doctors, hospitals, etc.)
c. Systematically develop and publish standard educational materials to (a) educate patients on the various diseases, tests and treatments; and (b) to educate patients on the meaning of the published provider quality metrics.
With the information provided by AHQES, consumers would be empowered in their proper role as comparison shoppers for medical goods and services. And doctors would be empowered in their quest to select only the most effective and least dangerous tests and treatments for every patient.
Sincerely,
Dan Jones
Thanks for your interest in real health care reform and for what you are doing.
Tort reform is absolutely essential to any meaningful reform and is long overdue
i would like the senator to explain why this wealthy nation cannot do what other wealthy nations do, and that is provide at min, basic health care to its citizens and at the same time doesn't force people into bankruptcy in order to pay for life-saving treatment.
Almost every primary care organization and every medical and surgical specialty society have practice guidelines for almost every diagnosis we see. Many even have "appropriateness criteria" to help practice evidenced based medicine. Senator Cornyn should support the concept of letting real (community & academic) doctors lead this important charge for our patients. Physicians are extremely competitive and we do want to prove the quality of care we give. We don't need to duplicate what we already do on a daily basis. Let our professional societies provide the mechanism to prove our quality of care (NCQA, etc).
P.S. After the CMS rules go into effect and the additional 21.5% cut in 2010 there won't be many doctors able or willing to provide highr quality care to patients. If protesters in Iran can orgainize to march against an "election", Someone in our leadership needs to organize a protest to let congress and the rest of America know that cutting reimbursement to physicians is a deadly serious matter. We all have to stand together.
TORT REFORM: True tort reform would decrease the size of huge settlements but would also decrease other negative effects of the system: Merely being sued negatively impacts a doctor's practice, even if we don't count mental angush. The amount of time spent in depositions, corespondance etc. can cut down on time to get some work done. The remote effects of a settlement or case decided against a doctor
have implications regarding credentialing, staff priviliges... The upshot of this is that most specialists will order a test if there is a 1:10,000 chance that the illness is present. There is no personal impact of ordering extra testing, but major impact of missing ANYTHING. No doctor is willing to jepordize his ability to keep up mortgage payments even on a 1:10,000 odds, if there is no downside to ordering the test.
SECOND: A major cause of our healtcare crisis is that our system covers, even encourages, care that no other country even considers. I'm thinking about all the ICU care and end of life care that keeps poor old granny alive, even though she barely recognizes her family. I've had to put these people on ventilators, at family insistance,
even though all I really did was burn up dollars and postpone the funeral.
THIRD: Even though I see many problems with the healthcare system, it is easier to see issues with the one sided 'survey' we were asked to take. All the members of this group do not agree with any of the answers to the survey questions.
I WOULD LIKE TO CALL ON SERMO TO FORCE THE SURVEYS TO BE MORE EVEN HANDED RATHER THAN JUST ALLOWING CHOICES ALL BASES ON THE SURVEYORS POSITION. These politicians need to see who does not agree with them and SERMO needs to develop a reputation as apolitical and even-handed.
Macleod -- I think you are very articulate
Senator -- there are lots of ways to reform health care; most of them being considered (and all of them looking to government to "solve the problem") will not ultimately be helpful. The first thing we have to get over is the government is needed to, or even CAN fix anything here. As a pediatrician, I frequently remind the parents in my clinic that doctoring is a lot like parenting. The stakes are huge, great effort and dedication are needed, you do your very best, but there are no guarantees. The more we try to guarantee something, the worse the outcome is likely to be.
No innovative solutions ever came from a government-planned program; it didn't work for Stalin, and it won't work here. PEOPLE are innovators but only when they have the freedom and incentive to do so.
If you want HELPFUL healthcare reform, (1) stop trying to guarantee everything to everyone (including re-election); (2) allow doctors out from under 3rd-party-controlled reimbursement restrictions; (3) give people choices (on types, amounts, and locations of health insurance, health care providers, etc.); and (4) give people (including patients, insurers, lawyers, and physicians) accountability for their choices. Then, take a deep breath, prepare to perhaps not be re-elected because you didn't guarantee, but watch innovation flourish, efficiency improve, and costs come down as competition and innovation arise.
Everyone must buy health insurance. It is like car insurance, portable, and regulated in the same way. It is not coupled to employment. Each state should set minimum standards for the coverage. Cost-effectiveness is improved when it directly correlates to each state's uniqueness. Like car insurance, companies can compete for the business, and rate people to pay more for risky behavior that costs money. Just as states have a mechanism to take care of drivers that cannot get insurance because of past driving records, health insurance companies can be required to accept a percentage of those enrolled, of these high risk patients at a rate that is some percentage of their lowest rate. This will incentivevise them to charge enough so that they can cover the high risk patients, because they know that they will get stuck with them later.
Although I see this as state programs, we can improve compliance. Employer are mandated to deducted from their pay pre tax and paid to their chosen insurance company. Those now covered will receive the health insurance money now paid by the employer to the insurance companies. If the new chosen insurance is less than what was paid before the money goes to the employee (The employer can be comfortable knowing that he will never see his health insurance bill increase). Those not covered will have the money for the minimum state required coverage deducted pre tax. For the generation who paid for Medicare, that money Medicare can pay to their chosen insurance company up to the amount of the standards set by the state. Every one else must pay for themselves, pre tax.
But what if you can't pay? Those below some percentage of the poverty level will need government help to pay, like Medicaid, but on a sliding scale. Some states may choose to get bids from different insurance companies to get the contract to cover these subsidized plans. For the really poor, rather than Medicaid, I would like to see a return to public clinics for the poor, like we had before 1950, to be staffed as they once were: All physicians (from the top and the bottom of their class) are required to give 5 hours a week. It would be healthy for all of us, not just physicians but also Therapists (Physical, Occupational, etc). The clinics can be run as the state wishes and staffed by the state. I would recommend a staff of nurse practitioners to compensate for the demand and shortage of primary care physicians.
Those who do not comply have broken the law. They will get emergency treatment. They will also get fined as they would for breaking any other law. Wages can be garnished until the bill is paid. I am sure lawyers can expand this into a longer document but not 100 times more than the US constitution, costs trillions, and disenfranchises us from making our own medical decisions.
Iressa was approved by FDA in May 2003 based on the surrogate endpoint of tumor shrinkage in 10% of treated patients. FDA restricted its use in June 2005 after further trials failed to demonstrate survival benefit. However, this is not the end of the story. It was subsequently found that a mutation in the tyrosine kinase domain in EGFR correlates well with responsiveness and tumor-free survival to tyrosine kinase inhibitor, and not all EGFR mutations are equal. Life is much more complicated than we thought.
Lung cancer requires individualizd treatment and subgroup patinets, such as women, non-smokers with adenocarcinoma can do quite well. The potential benefit of this subgroup patients will be denied by the CER.
I bet each and every physician here can provide hundreds of examples showing the folly of CER. As many have said that medicine is complex, dynamic, and fluid; life would be much easier and simpler for us if we can practice medicine and provide the best care possible to our patients simply following the guidelines from CER.
Thank you for your interest and my apology for the impolite comments above. It is a mystery to me why comparative effectiveness research is controversial at all. Too much of what we do in medicine is based on expert opinion and not enough on cold, hard science. Any entity, be it private, nonprofit, industry, or governmental that adds to the body off knowledge is welcome. Sir, I think your cynicism about the federal government's intent in such research is misguided and I would encourage you to not let your idealogy blind you to common sense idea that we physicia need to learn how to do it better. I think doing it bettter usually saves money. But more importantly, we neeed to know what is effective. Once we know wht works and how well, it is sound public public to have a discussion on how much we value the outcome and if the cost is wirtg. Resources are not unlimited.
Finally, sir, if you are trully in search on enlightment on comparative effective research, get opinions from numberous physician groups, not just Sermo.
>rarmstrong=Agree & concur, passim;
>olddoc2, 11/04/2009, 4:39pm=Masterfully succintly stated as well as correct & accurate!
>sgmor, 11/04/2009, 4:55pm=Why would a 'public option' not prove as unaffordably expensive as our present system without reforms suggested by olddoc2 (e.g. med-mal reform being the leading one).
>surgonc. 11/04/2009, 4:19pm=OK, maybe--just maybe--Comparitive Effectiveness R&D, within reason, might help to contain costs (at least over time) but vide infra OpticsThinker.
>OpticsThinker, 11/05/2009, 10:00am=Identified the med-mal impediment to CERs (i.e. the plaintiff attorney citing individual pt risk factors) but maybe this impediment might be overcome by what another Sermoan (whose 'thread' I cannot locate just now) suggested, i.e. in the State of Maine, adherence to Comp Effective guidelines may be used as a 'shield' (or 1st line of defence) against malpractice litigation.
>Sermoans in general: Hey, OK the polling questions probably are kind of inane but the real merit of Sermo is not some silly polling questions but, rather, the 'add your comment', the forum of discussion (as hyperbolic as some such turns out to be).
Senator Cornyn: Thanks for at least listening to the medical community at large. Here's a thought: why not suggest to one of your Liberal Left colleagues (Chuck Schumer of NY or Kerry of Massachussetts come to mind) that they post an opinion poll & discussion on Sermo--should prove interesting, if only for purposes of contrast!
Compartive effectiveness is in my mind another "paradigm" BS word capturing an important idea and then offerered as a majikal balm to solve problems poorly appreciated and less understood to individuals with way too much power.
Research to make us a better country is vital. We dont want the russians beating us at our own game. Cleveland clinic and Mayo clinic draw royalty from around the world yet our free market system is being cited by those with upturned noses as falling behind countries that didn't have the courage to stand up to terrorists. - Freedom fries anyone?
We can't allow this shame to stand, else we deserve to lie down and take in the head. The united states, although stunted by the past severel years is not so far gone that this cannot be mastered.
Research in the proper hands, used the proper way is the cornerstone of a scientific community that has drawn royalty. Comparative effectiveness could help us know if lower cost therapies are just as good as more expensive ones. This could give us backbone to stand up to self serving patients who will not accept generics (MA patients are the worst). better yet we could stand up to self serving lawyers, and the same ventures that has served a long term corrosive effect on parsimonious therapy.
I am a physician, so obviously I would be biased to eliminate any hinderences to my well being. Therefore anything I say regarding tort reform will carry no real weight with most reviewing my statements.
I believe you may have already stumbled upon the solution. I do understand the SGR voting was not acceptable to the GOP. I was surprised as GOP usually supports those at higher tax brackets. I realize however parsing out the continued payment of MD's what it already costs - into another bill was a cheesy trick to hide the enourmous cost by the Dems. I'd rather not delve on the upcoming vote, as views of both parties have been well represented here (and I apologize for my uncivilized compatriots - but if it is OK for them, it should be OK to cite when the president is "mis quoting" again.)
Back to the SGR. I now call it the SGR bomb. The ticker set by a certain individual who made me a republican years ago. It continues to tick.
You see, the public thinks doctors cost too much, and should be sued. They are not worried that unregulated litigation poses them any threat.
They need the SGR bomb. When it goes off, My practice rates a 40-60% chance of ceasing to exist. I already refuse new MA. Will I have to refuse Medicare?. Ah the suspense of it. I've learned that raw capitolism is a bit irrational. Many will think doctors are paid too much even when the last doctor's office is closed. Then, just as the stock market has done so many times in the past, it will whip the other way.
I open this 3 day old email tonight, Sunday as, literally- as we speak, on CNN the Congress men and women are voting already. I mention this to say reaching out to doctors who actually see patients "on the front lines" has been essentially an afterthought in a process that has been going on for many months. Most of the input from doctors to date has been from those who make enough to worry about tort reform. They pay huge malpractice insurance policies because they can afford to and the insurance companies will keep collecting these premiums as long as they can get away with it. Be honest. The true benefactors of tort reform are the insurance companies, not the majority of practicing physicians. Don't pretend you are doing all doctors such a huge favor by saving the insurance companies money. Primary care physicians who work primarily in the office "on the front lines" and haven't been sued repeatedly don't pay but 5 - 10 thousand a year for insurance. Many times they don't earn in a year what the tort reformers pay for malpractice. For more insight into the thoughts of primary care docs I urge you and those reading this to read a couple of other postings here on Sermo and check out what a significant few of my colleagues and I are thinking.
md.sermo.com
md.sermo.com
Hopefully more will chime in on the conversation and let you people know what's really going on.
As for defensive medicine, except for settings like the emergency room, defensive medicine is also a minor problem. If more patient encounters were in the doctor's office or provided by doctors who are familiar and have rapport with the patient there would be less defensive medicine. Over the past several decades, the practice of medicine has evolved from the practice of what's good for the patient to the practice of "what's covered." To often, if it is not covered it does not get done. "Not covered" is seldom synonymous with not appropriate or unnecessary as the more marketing saavy insurance industry would have the politicians and public believe. In fact, the ongoing debate is largely about who will be covered, what is going to be covered, and how it will be paid for-or more precisely- where will cuts be made to cover the additional expense. It is not accident that people who actually see patients for a living all day every day have largely been excluded from the conversation. Because the people involved don't run private offices or actually see patients-including the doctors involved, the debate has not considered sufficiently the concerns of primary care doctors regarding the logistics and economics of patient care. Specialists and surgical types, more notably represented by the AMA and those in the political know, who make enough to worry about tort reform have been included in the conversation as if their interests were representative the other 80% of the profession. The politicians (who get huge campaign donations from the insurance companies) and hot-shot docs are busy talking about tort reform. But no-one has addressed the potential mass exodus of 40-60 year old primary care docs after they cut the budget for everything but highly specialized procedures performed by people who pay high malpractice premiums. The tort-reformers aren't going to renew all those prescriptions for generics instead of a better drug. They aren't even going to do the paper work to obtain "prior authorization" so the tort reformers can get paid for a consultation or collect 4 or 5 figures for a 30 minute procedure. It makes no sense for a doctor who gets $40 for an office visit to have to spend hours doing paperwork so a drug company can collect $200 for a prescription. This whole healthcare reform debate is meaningless if these type concerns are not addressed. When Granny gets a fever on the weekend, no one going to call President Obama, nor anyone worried about tort reform or defensive medicine. It is a shame that whoever has to workup her fever will have to spend time worrying about which insurance she has and "what's covered."
The truly important concerns that should be emphasized in the healthcare debate pertain to the reasons why people don't have a doctor and why there are too few primary care doctors and why people have no choice but to go to emergency room for care. The lack of available preventive care and cost-effective management of chronic disease has not made anyone's agenda. These concerns have largely been ignored.
The concerns about medical liability reform and defensive medicine are more the concerns and priorities of the insurance companies. If there is to be any meaningful comprehensive healthcare reform, there needs to be at least a feigned interest in the concerns of those who will provide the services that your campaign contributors don't want to pay for.
Thomas J. Locke, III MD
I do not believe that most lay juries know much about medical competence or care about evidence based guidelines. They are guided by the patient's injuries shown to them by a skilled malpracice lawyer and the resultant consequences to the patient and his family.
The emotions of the jury, which is not a jury of "peers", play a much greater role than can be controlled by factual evidence.
In other words, we will all have insurance, but none of us will have doctors.
Meta-analyzes attempt to provide more robust information by reviewing mulitple studies in a cogent manner. It is important to understand the difference due to the very nature (entry criteria) of the studies - e.g. UKPDS/DCCT=EDIC v ACCORD in the very diagnosis (and prior treatments) of a disease with long term complications; or difference in protocol and potential effects e.g. ACCORD v ADVANCE.
Shame on all of your colleagues who have left us without protection. We have dedicated our lives to caring and noone in washington cares about us. We are a precious resource and you are squandering us.
Please ignore the rude responses from some of our colleagues. I had the opportunity to meet with my representative this summer. Although I heartily disagree with her on just about every issue, we were able to have an entirely pleasant and polite discussion about the topic of healthcare. There is no need to devolve into uncivil behavior.
As for guidelines: I work in the ER. On the one hand, guidelines do assist in creating a decision tree. However, final decisions are dependent upon individual needs. For example, when the much-touted pneumonia guidelines arose, they required antibiotics and blood cultures within 4 hours of arrival. Sounds great, right? Well, there's a few problems. One, not all patients with pneumonia require hospitalization. If they don't require hospitalization, they usually don't need cultures. Two, some cases were not diagnosed in the ER - but we were held accountable for failing to provide antibiotics. This is a very simple example.
In the ER we aren't usually faced with the myriad of choices other specialists confront, but there are still "game-time" decisions: whether to send the 96 year old with gait dysfunction home at 10 PM; whether to give thrombolytics or transfer the MI to a cath lab; whether to intubate the CHF patient or use BiPap. You make these decisions with your patients. No bureaucratic guidelines determine my choices in those situations. I stick with science, even if the government has yet to catch on.
It goes without saying (and it seems to remain unsaid!) that tort reform must be undertaken. The failure to bring this to debate is an abomination.
I would like to believe that you posted these questions because you (and others) on the hill really are concerned, however I can't bring myself to overcome my skepticism.
We are rapidly creating a system where the brightest and best are avoiding medicine a profession and soon we will find ourselves being cared for by NPs, PAs, and Nurse midwives completely. I was a PA prior to medical school and can tell you, -- they are invaluable but the education does NOT compare! More and more new physicicans are " part - time" and I can tell you, there is no way you can learn the ART of medicine and practice efficiently by "dabbling".
The idea of "evidence based " medicine sounds wonderful, but it does make me cringe. If everyone has to follow the "outline" of evidence based treatment, how does one take into consideration of the ever varying responses of each individual to treatments and further more, how is anything new or better ever discovered if one is fearful to venture away from the accepted "blueprint"?
The government is making it near impossible to afford to keep a practice open. I live in PA where malpractice is a disgrace and this year our Governor and the state legislature agreed to raid the "M-Care" fund that doctors pay into every year to subsidize malpractice claims for the purpose of balancing the state budget. Now, if that isn't a TAX for simply being a physicican, I don't know what is!!
One last point --- last year the Blues contacted us and told us in our practice that they were not increasing our payments in our fee schedule. ( We have been waiting and asking for a new fee schedule for over 5 YEARS). Within the same month, the Blues also informed us that our premiums for insuring < 14 people in our office was increasing over $50,000 dollars. There you are - We don't need health care reform, WE NEED INSURANCE REFORM.
1) Tort reform must occur. No fault insurance offered to all, with expert panels of MDs and judges to decide fault and compensation will save over 100 billion yearly. Eliminate trial attorneys, and malpractice costs will decline, and compensation for bad outcomes will improve.
2) CER- Sounds good, but will be subject to abuse by government. Yes, guidelines are acceptable, and yes, best treatments should be sought and promoted. However, when big govt gets involved, a la Medicare, guidelines transmogrify into punishment and then banishment from the program, and possibly criminal sanctions (see RACs). So if utilized they must be separate and distinct from the government entirely. Many, many issues in medicine have not been and will never be studied via CER. Some could not be due to the simple liability of doing so. Would we ever try to wait longer on antibiotics for appendicitis? It is not as simple as the bean counters would like everyone to believe. And therefore I believe there is danger in allowing them to try to codify and enforce the art of medicine.
Thanks for your time Senator.
tests I realize that politicians don't know what it is like to practice in the northest. Patients here will not agree to anything without every possible test known to man. I have had patients with quite obvious diagnoses who refuse to have surgery unless they have a CT or MRI or both. If you don't get these first, they threaten to file complaint with whomever will listen. Then, if you were brave and did get them to forego the preop testing, and they then have a complication your ass is on the malpratice carpet.
The battle cry of health care reform is at best a farce. We currently have a system that most people are happy with. Cost of this care has become somewhat of a problem. So have expectations of the public. They have had access and even demanded rights to expensive technology, drugs, and treatments all at little or no cost to them.
Some changes are needed:
1. Axe pre existing condition rules for non coverage and waiting periods- The house bill that passed even has this in it. What's up with that??
2. When you switch jobs- insurance should be portable.
3. You should be able to buy insurance across state lines. This should lower prices.
4. Small business and individuals should be able to form non government sponsored coops to increase the risk pool.
5. Tort reform. The house bill prohibits states from capping awards and limiting attorney fees without suffering economic repercussions from the feds. Also if the attorney fees are not limited, why the hell are my fees being capped? I've never seen an attorney treated patient get better.
6. Fix the SGR problem. You cannot plan for the future, build facilities, or expand services if nothing but cuts are on the horizon. The country is aging with the over 65 group leading the way. If you have more pigs at the trough you have to put more feed in. The idea you can have medicare go from 48 million to 80 million patients over the next 20 years and only allow reimbursements to grow at the rate of GDP growth means continued cuts to providers and rationing. Physicians don't control tax policy and don't deficit spend. You should be very worried when US debt is offered on the open market and nobody is buying. Instead, rather than cut your spending, the federal reserve prints more money. Increases in money supply increases probability of inflation. The only way out of this is to increase revenue ( taxes). However, increasing the tax burden on society DECREASES GDP growth. Compare Denmark and France to Hong Kong and Singapore. Compare tax burden to GDP. Medicare and Medicaid act as insurance companies. Where are the reserves required of real insurance companies? We have an aging demographic, as does Europe and China. Old people have more medical problems and cost more money. As the young well pool declines relative to the older pool, costs have to rise. Congress screwed this up with politics instead of statesmanship and the egg is on your face, not ours. Every other business needs a profit margin to operate. Physicians do too.
6. Why is there no cost to the public on lifestyle? Smoking and obesity causes multiple morbidity and mortality problems thus increasing health costs. US is the fattest developed nation. Some burden needs to be placed on the public for bad choices. I can't take the twinkie out of your face.
1. Increase government control by people that are not practicing clinicians.
2. Why are we overhauling a system that works for 270 million to insure 45 million when 15 million are here illegally, another 5-10 million could have insurance and choose not to. 20-25 million are too poor or too sick. A possible role for the government would be to act a re insurer for catastrophic loss. In Kansas, you buy malpractice commercially up to defined limits and you pay into the state fund for higher limits that seemed to stabilize prices. We can fix what is wrong with this one without socializing the country. Every one points to European health care. Show me a European country that is not more socialistic than the US.
3.CER's Not that research and guidelines are bad. Non physicians love guidelines. The problem is they don't know if they are looking at good ones or bad ones. They don't look at the underlying research and the biases of who put them out. Thus guidelines are treated as de facto law. I once had a medical director of a insurance company, trained as a proctologist, arguing with me (PM&R specialist) as to the experimental nature of electrical stimulation( it has 50 years of use and data). I told him the data did not support his position. I told him not to tell me how to do rehab, and I wouldn't tell him how to treat a**holes. The stimulator was approved.
4.Payment rates less than the cost of providing care. We need more rather than less physicians. The cost of medical education and the poor reimbursement situation- who's going to go into medicine? Maybe if we got the same retirement and health benefits as you do, we may not have to worry about our future so much. I AM amazed at the boldness of the political hypocrisy. Offering health care reform. Telling the masses how it will save the country. The politicians aren't willing to mandate government employees and themselves be on it. Quite frankly, that's BS. If its good enough for us, its good enough for you.
I had hoped to be more responsive to some of the comments and questions raised in this discussion, however the recent events at Fort Hood in Texas have consumed most of my time over the last few days. I ask for your understanding and prayers for the victims and their families. I look forward to continuing the discussion with this community in the coming weeks as Congress continues to address healthcare reform.
Yours,
Senator John Cornyn
Best wishes
GB
Thanks for your time and input. Some basics are important and good to return to whenever things get too complicated;
1. VA Info System- Can't we give this to everyone who practices healthcare. Government could keep up and would need IT folks to work on protections, but easy to see, could be billed automatically, and reduce reduplication. The government really wants to help, this is one way!!!
2. Self-responsibility- Until folks are in charge of paying/managing their care through aaccounts which they are responsible for/manage, no change in costs. healthcare is one of the only things that the provider and recipient often don't know the true costs of.
This has to change with some carrots being used.
3. Malpractice-talk to senator Coburn about ideas Sermo folks have given. MDs should be punished for urely blatant things (sex w patients/rampant fraud). However, when did malpractice become the source of wealth. There has to be a balance!!
Thanks for your time and keep up the good fight. We also need to hold the insurance companies responsible. A staff member told me insurance is like toothpaste, private insurers squeeze the tube and put extra paste on their CEOs/shareholders plates and government spills the paste in the sink (waste)!