Questioning Effectiveness

To save both lives and money, most countries with single payer health care systems support, or at least monitor, research on the cost-effectiveness of drugs and medical procedures. One of the less well known provisions of the Affordable Care Act is a plan to support comparative effectiveness research. The bill creates a Patient-Centered Outcomes Research Institute, a nonprofit organization charged with conducting research on the comparative cost-effectiveness of various medical treatments and making recommendations to health care providers.

An Associated Press article reports that, beginning in 2012, the government will collect a fee of $1 per person from health insurance companies to cover the cost of the new agency. The fee goes up to $2 in 2013, and rises with the inflation rate in subsequent years.

I can remember a time when virtually everyone agreed that program evaluation—now called comparative effectiveness research—was an important scientific endeavor. Why should anyone suffer through and pay for a drug or medical treatment that doesn't work?  If two treatments are equal in effectiveness, shouldn't only the cheaper one be covered by insurance? By coincidence, today's newspaper has two articles implying that current evaluation research is inadequate. All-metal hip replacement implants are breaking down after a few years, causing endless suffering to those who have received them. And Chantix, a quit-smoking drug that is only slightly better than a placebo, apparently has adverse side effects that include violence, depression and suicide. (“The good news, Mrs. Obama, is that your husband has quit smoking . . .”)

But the consensus over evaluation research began to break down when American corporations and their friends in the Elephant Party declared “war on science.” Although its origins can be traced to the 1960s “debate” over the health effects of cigarette smoking, the war began in earnest about a decade ago. As a result, many Americans believe that scientific research is inevitably biased, that scientists discover non-existent problems just to supplement their incomes, and that the consensus conclusions of experts are just another opinion, no better or no worse than, say, Rush Limbaugh's opinion.

Combine this with a distrust of government and you get claims like that of the Elephant beauty queen Sarah Palin that the Jackass Party is trying to set up “death panels” to ration medical care. (Yes, Gov. Palin, health care is being rationed, but not by the government.) In the current political environment, there is a very real possibility that this new agency's research will be wasted because every conclusion it draws will be endlessly disputed.

A second problem is evident in the Elephant-friendly way the AP article presents the fee—as a tax. Obviously, the research institute has to be funded. But couldn't the Obama administration have found a way to pay for it out of general revenue, without making the source of funding so explicit and obvious? You can bet the insurance companies will publicize this fee for all it's worth, hoping to get consumers to blame their next $1000/year rate increase on the government's $1/year “tax increase.”

Gail Wilensky, a former Medicare administrator who supports the agency, is paraphrased in the article as saying that it “should focus on high cost procedures and drugs on which the medical community has not developed a consensus.” I disagree. The most important thing to do is to support research with maximum potential for saving lives. By emphasizing the cost-cutting implication of their research, Ms. Wilensky probably hopes to keep the agency from being trampled by a bewildered herd of Elephants. But you can't pacify this species. If you try to save money, you will almost certainly be accused of rationing care.

One of my resolutions for 2012 is to do an occasional series of posts on the values and pitfalls of health care evaluation research.   

It Ain't Over 'Til It's Over

UPMC and Highmark have agreed to extend their contract until June 30, 2013. Until then, people who have Highmark health insurance will not have to pay out-of-network fees. Certainly, this is good news. Credit goes to Jay Costa, Dan Frankel, Randy Vulakovich, Don White and all those state legislators who put pressure on UPMC to negotiate, and to Governor Corbett, whose unnamed mediator is said to have brokered the deal.

However, Highmark customers may want to hold their applause. News reports don't say whether there have been any changes in the financial terms of the contract for the period between June 2012 and June 2013. It's still possible that Highmark policy holders face an unpleasant surprise the next time new rates are announced. More importantly, this is not a permanent solution to the problem. A UPMC spokesperson pissed on everyone's parade by stating, “This date provides 18 months for UPMC patients to review the multiple competitive health insurance options now available to assure that their care will continue uninterrupted with UPMC physicians and hospitals.” In other words, UPMC's refusal to negotiate with Highmark will continue. Highmark customers with pre-existing conditions have been given a stay of execution rather than a pardon.

On November 29, Ed Grystar, Chuck Pennaccio and Tony Buba published an op-ed in the Pittsburgh Post-Gazette pointing out how the ongoing conflict between these two corporate psychopaths shows how much we need a health care system administered by people who are accountable to the public—a single payer or Medicare-for-all system. This new agreement gives single payer advocates another 18 months to keep repeating this argument to anyone who will listen.

Obama, the States' Rights President

Last week, Wendell Potter posted an op-ed about the Obama administration's pending decision on the minimum health benefits insurance companies will be required to cover under the Affordable Care Act (ACA). The ACA says that ten categories of benefits must be covered: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse services; prescription drugs; rehabilitative and habilitative services; laboratory services; preventive medicine; and pediatric services. However, the bill left it up to the administration to specify exactly what services must be included within each category. Consumer groups were hoping for a specific and comprehensive list of benefits. Insurance companies and employers who pay for part of their employees' health insurance argued that “affordability” should be the primary consideration. They lobbied to make the list as narrow as possible. Guess which group had the most money to spend on lobbying? Do I need to tell you the outcome?

The decision was announced by Kathleen Sibelius, Secretary of Health and Human Services, in a 15-page “guidance” released on December 16. In a sense, the President decided not to decide. The list of essential benefits will be left up to the individual states.  Each state is supposed to choose an existing health insurance plan as a benchmark. All insurers are required to either provide the same benefits as the benchmark plan, or coverage of equal or greater value.

States have wide latitude in selecting a benchmark plan. It could be any one of the following:

• One of the three largest health plans for state employees.
• One of the three largest small group plans operating in the state.
• The largest commercial health maintence organization in the state.
• One of the three largest health plans for federal employees.

Complicating the states' decisions is the fact that some of the eligible benchmark plans do not provide coverage in all ten required categories. It's not clear how that problem will be resolved.

The decision was accompanied by a flurry of states' rights rhetoric straight out of the Elephant playbook. Sibelius said, “We want to give the states the flexibility to choose an essential health benefits package right for them.”

Although the outcome of these state-level deliberations is uncertain, I think we can make some predictions with confidence. First, the decision ensures that basic health insurance will vary a great deal from one state to another, with resulting inequality of health outcomes. Secondly, since most of the possible benchmarks are from within the state, states whose residents already have comprehensive coverage are likely to continue to have it, while states whose citizens are underinsured will continue to underinsure them. Finally, the result of this decision will probably be poorer health care for U. S. citizens generally than had the federal government made the decision. I say this for several reasons:

• The states will have to pay part of the expenses of any expanded health care coverage. Even blue states like New York, California and Illinois are strapped for cash right now.
• The Elephant Party controls most of the state governorships (29, compared to 20 Jackasses and one Independent). Some Elephant Attorneys General are participating in lawsuits to have the ACA declared unconstitutional. Among the states where we can expect hostility to the ACA is Pennsylvania, where the Elephants control all three branches of government and typically refuse to even consult with the Jackasses on pending legislation.
• This decision will lead to a predictable stampede. Health insurance and Chamber of Commerce lobbyists will descend on our state capitols wheeling barrows of cash into the waiting arms of our public servants. In fact, this may be the greatest fundraising bonanza for state legislators in the history of the country. Public interest  groups will be even less able to compete than they were at the federal level.

For the Obama administration, this decision represents yet another concession to corporate interests that opposed health care reform. It comes in the wake of their decision in October to ditch those provisions of the ACA that promised long term care insurance. It is yet another in the seemingly endless series of broken promises by the President who promised hope and change.

David Steil, the President of Health Care for All—PA, has suggested that, because states' geographies and cultures are different, states should determine the health care coverage their citizens receive. I disagree. States have less leverage than the federal government to bargain effectively with hospitals, insurance and drug companies. More importantly, the likely outcome of state variability is that those Americans who have the greatest need for expanded health care coverage are least likely to get it. If you live in a progressive state, you might be fairly well insured against most health emergencies, but if you live in Texas, now may be a good time to look into that cemetery plot you've been putting off buying.  (A new Harvard study has estimated that 45,000 Americans die each year from lack of adequate health insurance.)

Anyone who favors the policy of having states define essential health care benefits must answer this question: What exactly is it about the “cultures” of states like Alabama, Mississippi and Texas that makes them want less adequate health care coverage, especially for their poorest citizens, than states like Minnesota, Oregon and Vermont? Are these cultural differences that deserve our respect?

Dan Onorato's Happy New Year

When Dan Onorato leaves office at the end of the year, he won't be cashing unemployment checks. On January 3, the retiring Allegheny County Executive and former Jackass Party candidate for governor will start working for health insurance giant Highmark as an executive vice president. He will be "head of the government relations team"--in other words, their chief lobbyist.

Jim McTiernan of Triad USA, the consulting firm that appears to have brokered the deal, said, "Having someone who can help [Highmark] navigate the political process is key." Onorato, he said, "has statewide connections--the knowledge base to get to the right levels and the right parties." Onorato, for his part, was sharing the love:  "I am thrilled to be joining Highmark, a great Pittsburgh-based organization that has a history of helping families and companies with their health and wellness needs." Since Highmark is a "corporate person," she is apparently best described as a philanthropist.

Onorato's salary was not made public, but the man he replaces makes over $1 million a year. His yearly salary as County Executive was $90,000. Rep. Jim Cooper of Tennessee famously quipped that "Capitol Hill is a farm league for K Street." A few years in Congress at a relatively modest salary can serve as a stepping stone to a lucrative career as a Washington lobbyist. Newt Gingrich is a prime example. You'll be happy to know that a similar career path is available to Pennsylvania politicians.

Happy New Year, Dan-O! Welcome to the revolving door between corporations and government. Can a revolving charge account at Tiffany's be in your future?

Moving Backward

If you are a supporter of single payer who believes that change in the U. S. health care system will be gradual and incremental, you probably support the Affordable Care Act, and you probably think any policy changes that move us in the direction of single payer are progress, while you oppose any changes that move us toward privatization. Medicare is the largest single payer system we have in this country. The members of the Elephant Party are nearly unanimous in their support of Rep. Paul Ryan of Wisconsin's plan to privatize Medicare. Up until now, they have been unsuccessful in getting any Jackasses to sign onto the Ryan plan. That has all changed. Sen. Ron Wyden of Oregon, a member of the Jackass Party, has joined with Ryan to propose a “compromise” plan to “save” Medicare. While it stops short of privatizing Medicare, it is a major step in that direction.

When the Affordable Care Act was being debated, supporters of single payer favored a public option to compete with private health insurance plans. Our thinking was that if the public option proved more attractive to subscribers, it would move the country in the direction of single payer. The Ryan/Wyden plan offers seniors a “private option” as an alternative to the single-payer Medicare, possibly in the hope that competition from the private sector will eliminate Medicare from the U. S. health care system (although they deny that intention).

The Ryan/Wyden plan is a premium support program, similar to school vouchers. Seniors will be given a certain amount of money to spend on health care. They will choose among several alternatives, including traditional Medicare and various private health care plans, most of which will cost more than the amount they have been given.

Here is a simplified version of Austin Frakt's summary of the plan:

• Private medicare plans will compete with traditional Medicare in an exchange. Private plans must offer the “actuarial equivalent” of what is available from Medicare. In other words, the private plans don't have to offer the same coverage as Medicare, but the coverage they offer must be of equal value.
• The premium support citizens receive is equal to the cost of either the second cheapest private plan in the exchange or Medicare, whichever is lower. If you choose a more expensive plan, you pay the difference. If you choose the cheapest plan, you get a rebate.
• Private plans may not reject an applicant for any reason; that is, discrimination on the basis of pre-existing conditions is not permitted.
• If this price competition doesn't work to contain the cost of Medicare, the cost will be capped at a growth rate equal to the growth rate of the GDP, plus 1%. This will be done by reducing support for the sector or sectors (hospitals, drug companies, etc.) most responsible for the cost increase.
• Anyone now over 55 will not participate in the new plan, which will not be implemented before 2022.

There are several potentially serious problems with the Ryan/Wyden plan. Again, I am indebted to Frakt for his thoughtful posts about premium support programs (which he favors, by the way).

• Although private insurance companies will be forbidden to turn away people with pre-existing conditions, they will find all kinds of ways to enroll only the healthiest people, i.e., by directing their advertising at affluent citizens. Traditional Medicare will be left with the sickest people, who will pay the highest fees. A process called “risk adjustment” is supposed to deal with this problem by increasing the rebate to plans that cover less healthy people, but this is after-the-fact and it's not clear how it will work.
• Private insurance companies often treat their customers badly. The deny necessary care and provide poor customer service. This can also be used to drive away the least healthy people.
• When it comes time to design the plan, Medicare will have no money to spend on lobbying and campaign contributions, while the insurance companies will be stuffing Congress-critters' pockets with cash. This virtually guarantees that the playing field will be tilted in favor of the private plans.
• Since private plans don't have to offer the same coverage as Medicare, but only the actuarial equivalent, it will be hard for seniors to compare the plans. The insurance companies have almost unlimited advertising budgets with which to confuse and mislead consumers. Most seniors citizens do not have a friend with a Ph.D. to help them pick the best plan, so many of them will make bad choices.

The combined effect of these problems will be to leave Medicare with fewer and less healthy customers. This will increase Medicare's costs, while weakening its bargaining power when negotiating with hospitals or drug companies over the prices of goods and services. This could eventually lead to the demise of Medicare.

When Walmart goes into a new community, they offer consumers heavily advertised “sales” for the first couple of years. (Since they have thousands of outlets, they can afford to run some of them at a loss for a short time.) The purpose is to drive other local retail stores out of business. Once they have eliminated the competition, they quietly raise their prices. It's possible that the insurance companies will begin by setting their prices unrealistically low, in the hope of sending Medicare into a death spiral.

It's going to be difficult to oppose a premium support plan. Critics will ask: "What can be wrong with offering people more choices? If you are really confident that single payer is more cost effective, why do you worry that people will switch to private health insurance?"  Some of our objections will sound as if we oppose giving people more choices because we are afraid they will choose unwisely. This seems paternalistic, and conflicts with most Americans' mistaken view that they are too smart to be influenced by advertising.

I apologize for the length of this post, but I believe that premium support programs are a serious threat to move our health care system in the wrong direction. The New York Times has come out in favor of premium support. The insurance companies have almost unlimited funds with which to bribe Congress and the President to pass such a program. In fact, I'm afraid that dismantling Medicare is almost inevitable. If that happens, it will be nearly impossible to pass single-payer health care in this country. How can you demand Medicare for all when there is no Medicare?

Early news reports have suggested that Senator Wyden is seen by his fellow Jackasses as a traitor for breaking ranks and suggesting major changes to Medicare. (Paul Krugman refers to him as a "useful idiot.") My guess is that the reality is quite different. They are probably grateful to him for offering them cover while they quietly line up to follow his lead. The insurance companies have millions of dollars to pass out. Right now, the Elephant Party is getting most of that money. But the Jackasses want it, and if they signal a willingness to pass premium support, they are likely to get a lot more of it. The results will be disastrous for single payer, and possibly for the country.

The Mourning After

Three years ago, President-elect Obama, while naming his science advisors, promised to take an entirely different approach to science than his predecessor. He said it was time to “once again put science at the top of our agenda.” Science is about facts and evidence, he said, that “are never twisted or obscured by politics or ideology.”

It's about listening to what our scientists have to say, even when it's inconvenient—especially when it's inconvenient. Because the highest purpose of science is the search for knowledge, truth and a greater understanding of the world around us. That will be my goal as President of the United States.

One area where the Bush administration flagrantly ignored scientific evidence was reproductive policy. They rejected any change that the Religious Right mistakenly assumed would encourage gay or premarital sex. This included their outright refusal to allow the sale of Plan B One-Step, the morning after contraceptive pill, to anyone without a prescription in 2004, and their refusal to allow sale without a prescription to minors in 2006.

Of course, politics would never trump science with the Jackass Party in power, right?

The other day, Secretary of Health and Human Services Kathleen Sebelius announced that the Obama administration would reject the unanimous recommendation of the scientific advisory board of the Food and Drug Administration that Plan B be made available to teenage girls without a prescription.

In defending the decision, President Obama said that Secretary Sebelius was not sure that “a 10-year-old or an 11-year-old” would be able to understand how to use the product. The age reference is pure propaganda, considering how unlikely it is that a 10- or 11-year-old will first have sex, then be able to afford the $40-50 per dose fee, and, finally, find a pharmacist willing to sell it to her. But what is particularly upsetting thing about the President's statement is that the FDA conducted studies specifically to test teenagers' understanding of how to take the pill. The FDA Commissioner wrote:

CDER (Center for Drug Evaluation and Research) carefully considered whether younger females were able to understand how to use Plan B One-Step. Based on the information submitted to the agency, CDER determined that the product was safe and effective in adolescent females. . . . Additionally, the data supported a finding that adolescent females could use Plan B One-Step properly without the intervention of a healthcare provider.

Not only did Sebelius and Obama ignore this advice, they dishonestly spoke as if such research had never been done.

It's hard to believe that the President will pick up any votes from the Religious Right as a result of this decision. But with the way the 2012 campaign is shaping up—with the Elephant Party choosing among candidates who seem to lack an accurate conception of reality, and with no challenger from the progressive side—the President apparently feels free to poke his most loyal supporters in the eye with a sharp stick any time he feels like it.

Finally, let me give a shout-out to Marie McCullough, a reporter for the Philadelphia Inquirer. The Pittsburgh Post-Gazette now has a cooperative relationship with the Inquirer, which undoubtedly allowed them both to lay off some reporters, but which resulted in her article being published in Pittsburgh. After describing pressure from the manufacturer to approve the sale of the drug, she made the following comment:

On the other side of the campaign were conservative religious and political groups. They believed easy access to contraception would lead teenagers to have earlier, riskier sex; overuse the backup method while neglecting more reliable birth control; avoid consulting physicians; and become victims of sexual abuse. With about a thousand studies of emergency contraception now in the medical literature, there is no evidence to support these beliefs, but conservatives continue to hold them. (Italics mine)

We live in a media environment in which reporters and editors slavishly follow a norm of false balancing in which every political opinion, no matter how far-fetched, is treated as equally credible, and reporters never mention evidence to suggest which side of a political controversy is factually correct. Ms. McCullough is to be congratulated. I hope she doesn't lose her job.

Never Mind . . .

Remember a couple of years ago when everyone had their knickers in a twist about "sexting"--teenagers sending sexually explicit photos over the internet? A 2008 survey showing that 20% of teenagers were dropping their drawers online was front page news. A prosecutor in Tunkhannock, PA threatened to charge three teenage girls with spreading child pornography. The moral panic was on.

Readers Digest, May 2009

Photo by habrahamson

It took a while, but cooler heads may have prevailed. A new survey by sociologist Kimberly Mitchell of the University of New Hampshire and her colleagues, published in Pediatrics, now puts the true figure at 1.3%. That's the percentage of minors who claim to have sent a sexually explicit picture of themselves over the internet—that is, a picture showing naked breasts, buttocks or genitals. Another 5.9% reported having received such an image.

How did the earlier survey come up with the 20% figure? It's all in the fine print. First of all, they included sexy but non-nude photos, such as teenagers in bathing suits. Secondly, their sample was a group of young people who had previously volunteered to participate in internet research. The Mitchell group did a telephone survey using random digit dialing, which generates a more representative sample. Finally, they included 18 and 19-year-olds—adults—in their survey. Voila! 20%.

Mitchell reports that other surveys have produced inflated estimates by combining sexually explicit texts and pictures, labeling them both “sexting.”

The 2008 survey that generated all the headlines was sponsored by the National Campaign to Prevent Teen and Unplanned Pregnancy. Their website states that they favor sex education programs based on evidence rather than ideology. Unfortunately, they seem to have designed their study to produce “evidence” of a greater need for their services. I guess you could call it agenda-driven research.