John Q.
Hundreds of thousands of Americans watched this weekend as a desperate father held a hospital emergency room at gunpoint and demanded a heart transplant for his dying son. Fortunately for everyone, it all happened in a movie, 'John Q,' which opened Friday
Los Angeles Times
February 18, 2002
'John Q.'s' Public Warning By Benedict Carey
Hillel Laks, M.D., Professor and Chief, Division of Cardiothoracic Surgery, UCLA Medical Center, Los Angeles:
"It's very important for people to know what their insurance pays for, and to know they can do something about it. John Q. could have gone to the company and said, 'I don't like this policy. I want to spend $100 more and get better insurance.' If he's willing to go shoot people to save his son, why can't he pay a little extra a month to make sure he's covered?"
http://www.latimes.com/features/health/la-000012439feb18.story?coll=la%2Dheadlines%2Dhealth
Comment: Professor Laks is a noted and respected expert on heart transplants. However, before he ventures further into expressing public opinions on health policy, I would emphatically recommend that he become more versed in the basic fundamentals of this discipline. He might begin by reading "Understanding Health Policy" by Thomas Bodenheimer and Kevin Grumbach.
Importunely, Dr. Laks' response represents the prevailing view of the leadership of the medical associations, of many business leaders, and the conservatives and many moderates who now control the political agenda. Their rhetoric is that control of health care should be shifted to the consumer, and this is done by defining the contribution of either the employer or the government and then allowing the beneficiary-patient to have "choice" of the type of coverage by contributing the balance of the premium. That "choice" for those with very limited income and assets, such as John Q and another 100,000,000 or so in the United States, either requires an often unaffordable premium, or requires that the individual select options with unaffordable out-of-pocket expenses. For the benefit of Dr. Laks and others that don't seem to quite get it, in health policy terms, this is called "defined contribution" and "shifting risk to the beneficiary."
In fact, everyone who is going to take a stand on issues of health policy should read "Understanding Health Policy." If individuals are going to support cruel and inhumane health policies, they should understand exactly what they are doing. In this age, they should not be allowed the intellectual laziness and the "Let them eat cake" insensitivity of proclaiming, "Let them have choice," and then walking away from the problem.
Understanding Health Policy: http://shop.mcgraw-hill.com/cgi-bin/pbg/0071378154.html?id=aaHGHsD3
Kip Sullivan, responding to the Wennberg et al proposal for Medicare reform:
I agree with your statement that Wennberg et al. have presented a compelling argument that Americans are exposed too often to overuse and underuse of medical services. And I agree as well that Wennberg is wrong to promote HMOs as the mechanism best suited to reduce overuse and underuse. However, I want to call attention to a proposal Wennberg makes that you didn't discuss which I believe is dangerous and doomed to fail.
Wennberg, like all managed-care advocates, believes quality (overuse, underuse, and misuse) can only be improved if the structure of the health-care system is changed, and if patient privacy is destroyed (or, at best, placed at grave risk). Wennberg shares two beliefs with Paul Ellwood and other managed-care advocates: (1) quality cannot be improved unless doctors are herded into large entities -- preferably HMOs -- that have enough power over doctors to force, cajole, and/or educate them into changing their practice style, and (2) patient medical files are dumped into large information depots, preferably national depots, and these depots are used by researchers to determine "best practice." Both beliefs, casually and frequently expressed by the managed-care crowd, have never been elaborated, and certainly never proven. I think both beliefs are nonsense. A thorough refutation of this nonsense would take up more time than I have today. I comment on just two issues.
The notion that doctors can improve their understanding of the massive medical-science literature only if they leave solo practices and join large networks of docs or HMOs makes several bogus assumptions, the most important of which is that the bureaucrats who head up the network or HMO do have plenty of time to keep up with the medical literature, and, given their superior knowledge and their managed-care tools (utilization review, financial incentives, etc.), are capable of forcing or inducing the army of doctors under their command to weed out the "bad practices" and nourish the "best practices." Just saying this seems to me proof enough of the silliness of this proposal, but if there are people on this list who would like to question this statement, please do. This is a complex issue and I'd be happy to expound.
The second premise I want to quarrel with is Wennberg's assumption that medical research has been shackled, lo these many centuries, by the absence of national or regional information depots containing all information on all patients. (To my knowledge, Paul Ellwood was the first person to make a big splash promoting this nonsense. He did so in a 1988 article for the New England J Med.) The problems with this proposal are numerous and mind-boggling.
The most serious problem with the notion that advances in medical science depend on researchers trolling through millions of patient files is that it pretends, without saying so, that the historic methods of advancing medical science were never any good, or were terribly inefficient. The gold standard in scientific research is, of course, the prospective, controlled trial. Trolling through patient files after patients have received medical care is, by definition, a retrospective methodology. You can do your best to control for variables that could affect outcomes, but as a rule you'll never control for all relevant variables with a retrospective methodology as well as you will with a prospective methodology. I'm not saying retrospective research is useless. I'm merely calling attention to an obvious fact -- medical science, excuse me, "identification of best practices" will advance faster if we rely primarily on prospective methods, and that increasing the number of retrospective studies based on huge information depots (as opposed to the old-fashioned technique of asking a sample of patients for consent and then reviewing their files) will accomplish relatively little. To put it another way, if we never create gigantic information depots, medical science will continue to advance by the same route it always has -- by basic research, by randomized (prospectively designed) clinical trials, by retrospective research using relatively small patients samples, by clinical experience, and by serendipity.
Note the advantage to patients in the old-fashioned methods of advancing medical science -- our records are used with our consent. Under the Wennberg proposal, all records (not just that portion relevant to the study) on all patients (not just a sample of patients) are routinely dumped into the depot and kept there till the end of time (which is a much longer violation of patient privacy than the period of time required by the typical old-fashioned prospective or retrospective study).
And I haven't even discussed the cost of the Wennberg-Ellwood boondoggle.
I think single-payer advocates should state clearly that one of the advantages of a single-payer system is that patient privacy will not be destroyed. To make that promise, we have to reject the HMO advocates' claim that quality of care can only be maintained or improved if patient files are routinely inspected by researchers. We should instead promote much more old-fashioned research, and more education of doctors and patients about the results of that research.