Editor's note: This is the first part of a two part column on the recently passed Healthcare Bill. Part two will be in Thursday's edition of the Murphysboro American.
Most people I know and meet in my day-to-day routine follow the rule of “no politics, no religion” in casual conversation. That rule, however, seems not to apply to the discussion on the recently-passed healthcare bill. Casual acquaintances, close friends, and strangers alike have all asked about my opinion on the bill. Healthcare dominated the news for much of 2009 and early 2010. Given that I work as a family physician, though, healthcare will dominate my days and my life’s work until my retirement many decades from now. All the same, when asked about my opinion on the bill, I can usually only muster an “I don’t know,” which, in all fairness, summarizes my feelings pretty adequately. I like and dislike different aspects of the bill.
I don’t like that the healthcare bill did not include a previously existing provision on end-of-life care. I have seen too many grown people having to decide what their dying parents would have wanted; this is the most difficult decision of many people’s lives. Did Dad want CPR? Did Mom want dialysis? Should we put Dad on a ventilator? A previous version of the bill encouraged all people to speak with a healthcare professional about their wishes, thus allowing people to decide for themselves what they wanted instead of pushing end-of-life decisions onto family members. This provision gained much press, gaining the name “death panels.” The provision never included any talk of euthanasia, as some suggested.
Probably most importantly, I don’t like that the healthcare bill does not really address what I see as the single biggest problem with American healthcare: the cost. We simply spend too much. About 15% of our nation’s economy goes toward healthcare. No other country in the world spends as much as 13%. The average industrialized, first-world country spends about 9%. Every (that’s right – every) industrialized country in the world, even those with socialized medicine, spends less per capita than we do on healthcare. I would find this spending acceptable if we had better healthcare measures than most other industrialized countries, but no statistics show this. At best, compared with other industrialized countries, the health of Americans is middle-of-the-pack or worse. The healthcare bill functions primarily by increasing spending on healthcare, such that our healthcare spending will likely rise in the next several years. We could easily decrease this percentage without having the actual health of Americans suffer, but the bill really fails to address this possibility.
The bill could have decreased healthcare costs by promoting the use of generic medications. In order for the FDA to approve a new medication, that new medication must have two studies showing that it works better than placebo, a sugar pill. This system has numerous flaws. If a drug has eighteen studies showing it to work no better than placebo, but two showing that it does work better than placebo, the FDA can and may approve that drug. Frequently, the studies performed by the drug companies in order to get medications approved fail to live up to the standards of good science. Once the FDA approves a drug, the drug company will likely undertake a large marketing campaign directed both at prescribers and at consumers in an effort to increase the number of prescriptions written for their new drug. Often, these marketing campaigns work, even though the science supporting the use the drug may fall short, so that consumers spend gobs of money on expensive new medications that work no better than cheap old medications.
I believe that drug companies should have to first show that a medication works better than placebo, and, if that works, they should then also have to show how well a new medication compares to existing medications. To give an example, a fantastic class of medications called ACE inhibitors has existed for decades. Well done studies have shown the ACE inhibitors can prolong the life of someone with hypertension, with congestive heart failure, or with a past heart attack. A new class of medications called ARB’s emerged several years ago; these work on the same pathway in the body as the ACE inhibitors and studies have shown that ARB’s also decrease mortality in those with hypertension, a previous heart attack, or congestive heart failure. Several studies done since the FDA approved the sale of ARB’s have shown that ARB’s are as good as, but not better than, ACE inhibitors. The only difference between ACE inhibitors and ARB’s lies in that ACE inhibitors cause a dry cough in 5-20% of people and side effect called angioedema (severe lip swelling) in about 0.15% of people (both of these side effects are easily reversible by stopping the offending medication). The ARB’s have a much lower rate of these side effects. Very importantly, though, ACE inhibitors cost about $50 a year. ARB’s cost more than $50 a month. I believe that only those who have experienced a cough or angioedema on an ACE inhibitor should receive an ARB. Currently, though, Medicare will pay for an ARB for someone who has never taken an ACE inhibitor with only a $3 co-pay to that patient, meaning the rest of the cost goes to Medicare. Drug companies spend a lot of money trying to convince doctors to prescribe ARB’s, and this marketing works. Literally thousands of dollars could be saved by forcing physicians to show that a patient had a side effect on an ACE inhibitor before an ARB would be covered. Literally dozens of similar examples exist in which a new expensive drug gains a large market share because marketing trumps science. The healthcare bill does nothing to push cheap, effective generics over expensive, not-necessarily-better brand names.
The bill could have decreased healthcare costs by including tort reform. Doctors have two motivations in caring for patients: make the patient well and don’t get sued. Physicians (me included) order many tests not because we believe that the test will provide some meaningful information, but because we believe the test will help our case if we’re sued. I’ll use ankle pain as an example. If any person comes into an emergency department in the United States with ankle pain after having fallen, that person will almost automatically have an ankle x-ray done, adding $60-$100 to the cost of the ER visit. The emergency room physician could use a rule called the “Ottawa ankle rule;” the Ottawa rule requires the physician to examine the patient’s ankle and apply the rule, which will tell if an x-ray is needed or not. About 60% of people who come to the ER with ankle pain need an ankle x-ray according to the Ottawa rule; the ER doctor could discharge the other 40% without doing an x-ray, at considerable savings. Most sources I found state that use of the Ottawa rule consistently would save the healthcare system at least $100,000 a year just in ankle x-rays. The Ottawa rule will miss an ankle fracture very rarely, but it’s a miniscule number. Even though the Ottawa rule misses a fracture extremely rarely, physicians don’t use it regularly because of fear of getting sued. If the ER physician doesn’t order an x-ray on someone who turns out to later have a fracture and the doctor is sued, the suing lawyer will certainly ask why the physician didn’t order an x-ray, even if the best evidence says that the x-ray wasn’t necessary. Plus, the physician really has no motivation to save the healthcare system money – the doctor makes no more or less money based on whether he orders the ankle x-ray or not. The miniscule risk of being sued simply overrules the science in this example. Once again, countless such examples exist throughout medicine. Again, we could save $100,000 on just ankle x-rays! But one court case can tarnish a physician’s record forever and can cost the physician a significant amount of money.
As another push for tort reform, the court system isn’t very good at policing physicians. I’ve read several studies on the matter, and most seem to indicate that only about 10% of doctors who were sued actually made a significant error according to independent physician panels. Also, only about 10% of grievous medical errors result in litigation. This means that the majority of physicians who are sued have done nothing wrong according to their peers; also, the majority of serious errors pass by without legal action. I believe that it makes no sense to allow lawyers, judges, and lay juries to decide when a physician has erred. Physicians require years of training to make nuanced decisions regarding patient care; I believe it’s wrong to ask those without similar training to judge these decisions. I believe the medical system should adopt a procedure similar to that of the FAA. When a plane crashes, the FAA investigates the crash with engineers, air traffic controllers, mechanics, and pilots – all experts. While lawyers almost invariably get involved, they have no input into the FAA’s final report on the crash. Independent, expert physician panels should also decide whether a doctor has made an error. The healthcare bill, though, changes none of this.
The bill could have decreased healthcare costs by including provisions on using evidence-based medicine. Evidence-based medicine is a fairly new concept, gaining popularity starting in the mid-1990’s. This concept states simply that physicians should practice medicine according to well-done studies published in reputable medical journals and the most recent recommendations of scientific societies (such as the American Heart Association or the American Academy of Family Practice). This sounds obvious, but doesn’t always happen, most commonly because doctors trust biased information from pharmaceutical companies or because doctors lack the time needed to review the immense amount of new scientific data regularly produced.
The healthcare bill could have decreased healthcare costs by simplifying billing processes. The billing processes for medical services confuse me to no end. Three patients may each see me for a simple blood pressure check and, even though our visits may differ very little, the amount of money my office receives for each of these visits may differ greatly. Multiple factors affect how much an office visit costs, including what rates the patient’s insurance company has negotiated and exactly what I write in the chart. Knowing what to charge a patient has become so complicated that doctors frequently charge the wrong amount. Different rules exist for office visits, nursing home visits, hospital visits, and procedures. Most corporations involved in healthcare have large billing departments who, in part, spend a large amount of time ensuring that doctors have charged the proper amount. Insurance companies, including Medicare, spend lots of money auditing doctors’ offices to ensure that physicians charge the proper amounts. The healthcare bill has a few provisions to try and help simplify billing, but these provisions don’t go far enough. The healthcare system will continue to spend millions of dollars double-checking doctor’s billing – millions of which contribute nothing to patients’ health.
In the end, I hope that the money spent will improve the physical health of Americans but I fear that the money spent will harm the financial health of America. I know only two things for sure: 1. We all need to do our part to keep healthcare costs low while keeping quality of care high; and 2. If you were to ask me again in 2020 what I think of the healthcare bill of 2010, I might be able to give you a definite answer. Maybe.
