The New York Times
August 19, 2001
by Milt Freudenheim

Charles B. Inlander, president of People’s Medical Society, a consumer advocacy group, responding to questions:

Q. Will patients’ rights legislation do anything for the 43 million people who have no health insurance?

A. Nothing at all. This isn’t a health care bill. It is about the business relationships between consumers and health plans. It doesn’t mean that your doctors are going to be better, that your hospital room will be improved or that you will get better medicines. The bill has nothing to do with improving the quality of health care or lowering the cost and it offers absolutely nothing for the uninsured. The only time this bill kicks into play is if you are in a managed care plan. For many members of Congress, this is their way of appearing to deal with the big issue.

http://www.nytimes.com/2001/08/19/business/yourmoney/19FIVE.html

Comment: After the patients’ bill of rights debate has ended, Congress will walk away from real health care reform. What are we going to do about that?

Beth Capell, PhD, a dedicated legislative advocate for the medically underserved, responds to today’s quote on the futility of the patients’ rights legislation:

On behalf of all those who fought for the Patient Bill of Rights here in California, I disagree profoundly with these observations. We discovered that many people who had health insurance were unable to get the care they needed. It is very much about the quality of health care and whether doctors, hospitals, medicines and other care is what people need.

In California, medical group insolvencies have led medical group managers to encourage physicians to see twice as many patients: that’s about the quality and, indeed, the safety of care. In California, patients were shoved out of the hospital when neither they nor their family could care for them–that is, if they had family members who were able to help. In California, before we enacted laws regulating drug formularies, people had their medicines switched with no notice–and no consultation with their physician.

Just because you have coverage does not guarantee that you will get care. That’s what the Patients Bill of Rights is about. The fight for universal coverage will be meaningless if it is not a fight to get people care when they need it.

The next fight is to destroy the myth that people who have no insurance get the same kind of care as those of us with insurance.

Beth Capell

Comment: Beth is quite correct. The Patients’ Bill of Rights does help to assure access, and every effort should be made to support the more effective U.S. Senate version. But again, that debate will end shortly, Congress will walk away from the issue of universal coverage, and we will have to ask ourselves, “What are we going to do about that?” Beth will be working very hard on this issue, but where will the rest of us be?

Albert P. Cohen, an authority on health finance policy, comments:

As someone who once directed government relations for a wholly owned subsidiary of INA Corp (later CIGNA) in all 50 states and as someone who has represented consumer interests as a hands-on lobbyist in Maryland, I would suggest that expecting legislators to take a lead on something like single payer is not realistic. Maybe legislators should be leaders but few are. Few politicians are leaders. The only reason the patients’ bill of rights has had any legs is because consumers have become upset about managed care.

The reason I am increasingly optimistic about the future of single payer is significant growth in support for single payer as is indicated by polling over the last ten years. There are a few groups that have taken a lead in working for a single payer system. While I can not comment about the tactics of the groups and therefore their effectiveness, my suspicion is that the most effective influence driving the change has been the increasingly obvious fact that the private health insurance industry has not worked even for those who have been covered by the products of that industry. Many academic types like Judy Feder and Ted Marmor warned candidate Clinton than managed competition was flawed. And their predictions have been correct vis a vis what we have seen recently with Aetna.

My question is what tools those of us who believe in a single payer system can use to speed up the move toward single payer and to counter the predictable opposition from the Dick Armey’s of the world.

I personally believe that we have to have a concrete costed-out product to sell, not just a concept. And we must have the tools to know how that product can be modified and with what fiscal and popular impact of those modifications will be. State differently, we must break down our obstacles into manageable components and solve those components. Moreover, we must not get discouraged and fall back into abstract excuses for failure. To use a sports metaphor, we must keep our eye on the ball.

Best, Al Cohen

Theodore R. Marmor, Professor of Public Policy and Management, Yale University School of Management, responds to Uwe Reinhardt:

This is a very low level of intellectual exchange, hardly worthy of Uwe. First, there is a straw man produced, then a commentary — based on Uwe’s participant observation–about the American citizenry. Not a word about the work on public opinion by, first, V.O.Key, and, more recently, by Ben Page, Larry Jacobs, and Robert Shapiro. In short, this is empirically uninformed generalizations, a subject that Uwe has strong opinions about. This reminds me of the fallacy of post-hoc, propter hoc, one that many economists are guilty of. If an outcome arises, it must have been because someone (group) wanted it and/or did not avoid it strongly enough. Ergo, what emerges must have been what was wanted/ or at least not sufficiently fought. This has little to do with explaining why America has the health care system it has, though the structure of our government–and the institutional advantages it gives to non-governmental interests does.

Theodore R. Marmor

Comment: Post hoc ergo propter hoc? – the great fallacy of logic that temporal relationships establish etiology. Is this or is this not a fault inherent in Professor Reinhardt’s discussion? Does “political will” influence government action? Does political will even exist in the presence of an uninformed and unconcerned electorate? Is it a fallacy of logic to propose that a disinterested public fails to create the political will that would be required to enact health care reform? Professor Marmor seems to reject the role of the the lack of public input into the political process, even though that, in turn, does allow for the enactment of private institutional advantages. In my reading of Professor Reinhardt’s comments, the concept of this lack of public involvement delivers a strong, implicit message, to which we shall return.

Fundamental to this discussion is understanding just what Americans do believe. Do Americans believe that individuals should be deprived of care simply because they cannot afford to pay for it? Suppose a teenage boy showed up at an emergency room with acute appendicitis, but has no insurance and no funds. Does anyone believe that he should be turned away? Of course not. What about the little girl with a potentially curable cancer, but with no insurance and no money. Everyone would agree that she must somehow be worked into our health care system, even if unable to pay. And what about the widow, who loses her insurance along with her husband, and then develops diabetic ketoacidosis. She too would certainly receive needed care. And the costs for providing care in each of these instances would be shifted to others, with all of us indirectly contributing through our unique, but highly flawed, American approaches to the funding of health care. But in this country, the costs of providing care for these individuals would be met only after they are forced into financial ruin or even bankruptcy. Does our egalitarian spirit that makes us want to assure that these people receive care extend to wanting them to face financial ruin? No, Americans are better than that. But Americans do have to begin to understand that these are the consequences of our highly flawed system of funding care. They have to understand that, with the same resources that we already have, we could provide insurance for these individuals and for everyone else in the nation. If they really did understand this, do you think that they might support that concept? They probably would, except for the hurdle that they believe that they don’t want the government involved, or at least they believe that they believe that..

But what do they really believe about government involvement in publicly administered programs of social insurance, specifically Social Security and Medicare? Well, they certainly want their Social Security retirement benefits, although many now want a much larger benefit. They agree that there must be some form of mandatory funding, or tax, but some believe that they can increase the return through private investment accounts. It is not the purpose here to debate the actuarial value of Social Security disability insurance, survivors’ annuities, progressive benefits, inflation adjustment of benefits, nor the excessive administrative expenses and risks of individual accounts. The point is that Americans do want government mandated retirement protection, and the majority still prefer public administration, and most of the rest would if they were fully informed on the issues. And Medicare? Focus groups now indicate that the majority do have some understanding of the privatization schemes, and they want a publicly administered Medicare program to always be there for them. In fact, they not only want Medicare to be protected, they want the benefits increased, especially to include pharmaceuticals. They want a bigger and better Medicare program, albeit a government program. Although anti-government elements have been successful in feeding Americans the “we don’t want the government involved” rhetoric that they parrot, they have not been successful in convincing them that social insurance is bad. The problem is that we activists have not effectively delivered a message that they can believe and support, the message that universal social insurance for health care would solve essentially all of our problems with the funding of health care. Yet we activists continue to bask in our successes in health care reform.

Our successes? Look at them. Look at all of the legislative proposals that were successfully introduced. Look at all of the initiatives and referendums that made the ballot. Look at the various bills that were passed, lacking only the necessary funding. Look especially at the great numbers of successfully completed studies confirming our suspicions that we have serious problems in health care, in spite of our great resources. Look at the studies that have demonstrated that we can provide comprehensive care for everyone with no increase in expenditures. Look at the great body of literature in health policy that has expanded our understanding. In the past decade, our efforts have intensified, and our successes have escalated. And look at the numbers of the uninsured in the past decade… from approximately 32 million to 40 million!? And the numbers with inadequate coverage… accelerating at a dizzying pace now that we are “empowering” health care consumers. And an administration that has reduced the numbers of uninsured by 3 million… not really, but a manipulation of the numbers that reduces the pressure to do something, even if it didn’t really bring one more individual into the ranks of the insured.

Our decade of successes has left us worse off than when we began! And yet we have a nation that believes that they are complacent with the status quo… if only they understood. And that is where we have failed. There will never be reform without political will. And there will never be political will without a clear message from the people. And there will never be a clear message if the people don’t understand the real issues. And there will never be reform if we continue to fail in our task of informing the public.

Maybe Professor Marmor was looking for a different message. But Professor Reinhardt’s message jumped out at me from the computer screen. The message I saw? HEY! YOU ACTIVISTS. WAKE UP! GET UP OFF OF YOUR DAMN DUFFS. GET OUT THERE AND WAKE UP THE NATION! WAKE THEM UP AND DELIVER THE GREAT NEWS THAT WE CAN PAINLESSLY ACHIEVE EQUITY AND JUSTICE IN HEALTH CARE FOR EVERYONE.

Yes, that is Professor Reinhardt’s message. But it is our task.

Don

Uwe Reinhardt responds to Theodore Marmor

Earlier message of Theodore R. Marmor:

This is a very low level of intellectual exchange, hardly worthy of Uwe… (remainder of message deleted)

Uwe Reinhardt responds:

My dear friend Ted:

Although I always welcome your thoughts on matters of social policy, and often profit from them, I am less charmed by your easy habit of dismissing arguments you do not like with adjectives such as “low-level intellectual exchange” or “empirically uninformed,” or similar infelicitous phrases. It is not a good habit, Ted, and you ought to disabuse yourself of it. Please stick to the substance of the argument and forget the ad-hominem barbs. You are a smart fellow, we know; but so are others in this debate. You may have noticed that I disagreed with Kip, but I did not call him names nor characterize his arguments with infelicitous labels. The only one I called names may be the lethargic American citizen, but even here the label “teenager” was meant to be seriously descriptive. I do find something juvenile in the idea that one has rights and no civic obligations and, frankly, never did get my mind around the American people until our children had reached teenage years.

A year ago, at one of the Princeton Conferences, Norm Ornstein gave the keynote address. Perhaps you do not think well of Norm. I and many of my colleagues consider him an astute observer of American politics. It is the reason he was invited to give the keynote address at that august conference. One of Norm’s propositions that night was that any proposed health reform that might exact any sacrifice whatsoever from any politically potent constituency is dead on arrival. I rose to remark that, in so many words, Norm had characterized the representative American citizen as a selfish lout without any civic vision, without any willingness ever to bear some personal sacrifice for the common good. There was icy silence in the room at first. But in the end everyone, including Norm, agreed that that is basically what he had proposed; and he stuck to it. Implicitly, we all agreed that universal coverage was, therefore, a far-off dream, that we could at most make small, incremental inroads into the problem of the uninsured. Indeed, we agreed that we might be lucky merely to maintain the status quo. What have you, Ted, to say about that? Is Norm Ornstein wrong?

After the 1994 election, I showed my students a graph (it had appeared in the NYT) according to which voter participation in the 1994 election rose sharply with income. As I (vaguely) recall it, over 60 to 65% percent of eligible voters with incomes above $60,000 voted. For the lower income strata the ratio descended to the mid 30s. I remarked to my students that it is small wonder that our economy is being rearranged by the government mainly to suit the tastes of the upper half of the income distribution and, incidentally, that the quest for universal health insurance was more or less derailed for the time being. If the subjects of our compassion don’t even bother to vote, and if political activists like Pete Stark and Henry Waxman become imperiled anachronisms, who can help the poor?

Is it really low-level intellectualism to argue that the typical American has a more keenly developed sense of entitlements than of civic duties? Is it really low-level intellectualism to hypothesize that Canadians and Germans, who view their health systems as part of the cement that forges a group of people into a nation, may have a stronger sense of nationhood and the civic contributions that go with it? Are these observation so unworthy that they need to be dismissed with unflattering arguments and the recitation of sundry, allegedly illustrious names, rather than being debated on the substance? What about debating these arguments on the substance, Ted?

Finally, in the realm of politics, is the economist’s idea that “if an outcome arises, it must have been because someone (group) wanted it and/or did not avoid it strong enough” or did not fight sufficiently hard for an alternative outcome really so far fetched that it can be easily dismissed simply with an allusion to the “post-hoc, ergo propter hoc” fallacy, without the need to engage the hypothesis directly, Ted? If the economist’s line of reasoning is so wrong, what have political scientists to offer in its stead? Do outcomes just happen, without anyone either wanting them or opposing them or not sufficiently fighting for them? How, Ted, DO things happen, then?

I am aware that the structure of our government, in which political influence can be purchased retail, legislator by legislator, chairman by chairman, makes it more difficult to legislate clean health care legislation than does a parliamentary system such as Canada’s or Germany’s, where there is party discipline and where political influence must be purchased wholesale (i.e., the whole party), if that is legal at all. But to completely dismiss the voter in this picture, as you seem to do, Ted, strikes me as going much too far. Are you telling me, Ted, that the wishes of the electorate do not at all matter in our democracy, that structure is everything?

My perhaps politically naive theory would be that our system of government allows the electorate from time to time to put into power one of several rival elites, who then run the country for the duration of their term, mainly (though not exclusively) at the behest of powerful, moneyed interest groups or powerful ideological allies. The point is that the electorate does have the power to replace the elites at the helm. Surely that power is worth something, and the electorate can properly be held accountable for its exercise or lack thereof. Are you dismissing that power altogether, Ted? Can structure alone explain why a potential elite openly devoted to universal coverage (e.g., Bill Bradley’s campaign last year) did not have a chance at all at the ballot box? Did the electorate having nothing at all to do with Bradley’s demise? Did it just happen?

Don McCanne does a much finer job than I can in commenting further on your comment, Ted. Let me then leave it at that.

Best regards,

Uwe

Don McCanne commented:

(The message is deleted except for the final comment)

Maybe Professor Marmor was looking for a different message. But Professor Reinhardt’s message jumped out at me from the computer screen. The message I saw? HEY! YOU ACTIVISTS. WAKE UP! GET UP OFF OF YOUR DAMN DUFFS. GET OUT THERE AND WAKE UP THE NATION! WAKE THEM UP AND DELIVER THE GREAT NEWS THAT WE CAN PAINLESSLY ACHIEVE EQUITY AND JUSTICE IN HEALTH CARE FOR EVERYONE.

Uwe Reinhardt continues:

That is my message, Don. In my perhaps politically naive but nevertheless firm view, unless the political power of the lower-income strata can be concentrated on the problem of the uninsured, there is unlikely to be much legislative relief in that area (short of President Bush’s having another epiphany. Miracles do happen.)

I would assume that I had sent all of you a somewhat angry piece I wrote on this issue two years ago for the US Chamber of Commerce. Ted is likely to dismiss that one, too. But many esteemed colleagues thought I was right on the mark with that piece among them, for example, Peter Budetti. If you don’t have it, I’ll e-mail it to you.

Tom Mainor, provides two responses (before and after Dr. Reinhardt’s “bread and circus games” single payer commentary):

Aug. 14, 2001

I can understand that after all these years, Uwe Reinhardt is somewhat cynical and depressed at the current state of things. But Kip Sullivan is on target when he suggests that the American people have never been permitted to look at true alternatives without the pejorative labels attached. We have never really been provided a public examination of comparable health care systems and costs in other advanced nations. Nor has the press proceeded to examine why we are number one in spending and number 37 in results.

Corporations, with all their vaunted analytical resources and employee benefits, are pouring good money after good money into the corporatization of a resource that should be basic to civilized society. We would not corporatize fire departments and only put out the fires of those who had proper insurance. We would not allow ships to sink off our coasts because they did not have Coast Guard insurance… at least, I don’t think we are at that stage.

Our hospitals have been built in communities across the land, and funded by public (local, national and state), private, corporate and community-based fund-raising. They have been built for the simple reason that all of the above elements in society felt a need to have these resources. The sentiment and instincts to care for the vulnerable go back centuries. We do the same with VA and other health resources. St. Jude’s Children’s hospital here in Memphis is not in the business of making a profit off health care. They use abundantly provided resources to provide care for children–most often, children whose parents would never have the resources if the larger community had not provided such a place. This is multiplied across the land and the world.

The notion of publicly provided health care has a long tradition. HEALTH CARE IS TOO IMPORTANT TO BE LEFT TO THE MARKET PLACE. The bottom lines are the needs of the community, and how best to provide them. Universal access and globally budgeted health resources–including medical groups–is a way to use the abundant resources now being used for excessive administrative costs and for-profit entities. Salaried physicians in hospitals, e.g. trauma surgeons and others, as well as salaried medical professionals in medical academia provide often superior care to their for-profit colleagues….

Well, didn’t mean to go on so long… Cheers. Tom Mainor

Aug. 16, 2001

Masterful! Amazing! Sobering! Frustrating! Not the whole story! Perhaps with the brain power you have responding, there may be a way to begin to educate health professionals, some business and responsive and articulate journalists, and even a few political figures on various levels. One medical CEO here in Memphis told me he assumed the post as a right-leaning Republican. Now he is so disillusioned, he feels he has arrived at an almost socialist position. He is a good physician and CEO. More importantly, he really cares about how it all turns out.

One can understand Uwe’s despair, but we shouldn’t let the Limbaugh’s and the BushCheney’s of this world continue unchallenged. Ayn Rand’s philosophy may rule the day, but more fundamental human instincts, and the JudeoChristian (as well as other religious insights) still advocate providing for the care for and cure of the vulnerable and the sick in most societies. There are also progressive economic reasons for single payer/regional global health care budgeting that obtain which would improve both society’s and corporate well being. The Constitution also talks about providing for the general welfare, and advances the notion of a true Commonwealth.

Thanks to Uwe and his friends for the dialogue… Tom

August 9, 2001

“Medicare spending has also risen, by 8.4 percent. The growth rate has been accelerating since increased payment rates to health care providers took effect in April. For the entire year, CBO estimates that spending for Medicare will grow by 10 percent.”

http://www.cbo.gov/showdoc.cfm?index=2981&sequence=0&from=7

Comment: These numbers will certainly be used by those that want to “modernize” (i.e., privatize) Medicare, with the claim that the current Medicare program is inefficient. In fact, the traditional Medicare program has been much more efficient that the private Medicare HMO plans. Recent increases in Medicare spending have been only about 3 percent per year. Much of this year’s higher increase was due to intense lobbying efforts by the managed care industry. They were successful in gaining significant increases for their industry that were well in excess of the statutory limits of the Balanced Budget Act of 1997. We cannot allow the privateers to advance the claim that Medicare is inefficient, when the inefficiency lies primarily within their own industry.

Today’s message from Kip Sullivan, which follows in the next e-mail, you may be inclined to delete since it appears to be another long response in the current Reinhardt-Sager-LeBow-Sullivan series, and most of you are too busy for this. Please bear with us on this one. Sullivan describes one of the most important policy issues facing us today as we struggle with the issues of expanding coverage while containing costs. A major emphasis is being placed on controlling costs by creating patient-consumer cost-sensitivity, or “empowering” the patient-consumer in the health care marketplace. In reading Sullivan’s comments, I would suggest ignoring the challenge to LeBow in order to concentrate on the important policy behind his comments.

Don

Bob,

I disagree with your variation on Uwe’s criticism of “the American people.” Your version is that the American people are to blame for the world’s most expensive health care system because we want too many health services. You rested this rather controversial statement on the comment of a single patient that America’s health care system is expensive because Americans “expect the world.”

I make three points in this response:

(1) If we really must speculate on whether overuse of the US health care system is worse than underuse, the evidence should cause us to lean toward the conclusion that underuse is a worse problem.

(2) Your argument that “Americans expect the world,” even qualified as it was by your statement that our insane longing for medical services is abetted by corporate advertising, assists the right-wing in its quest to maintain a market-based system in the US.

(3) Your argument that drug company advertising is contributing to the high cost of health care is correct, but drug advertising is a minor issue compared to the other causes of the health crisis.

We do have some evidence that a few services are overused (e.g., bypass surgery and hysterectomies, and antibiotics), but we also have substantial evidence that the system is greatly underused. I’m thinking here primarily of the uninsured and the underinsured. I’m also thinking of evidence, including the Surgeon General’s recent report, indicating great underuse of mental health services. The seemingly intractable problem of low-quality nursing home care could also qualify as an example of underuse. I could list other evidence of underuse.

I won’t commit the mirror-image sin I’m accusing you of, that is, I won’t go out on a limb and say underuse of the US health care system is far worse than overuse. But I will say that existing evidence does not warrant the statement that “Americans want the world” and that this insane wanting is causing the US health care crisis. You can say it if you like, but you should note you’re engaged in pure speculation.

I believe the opinion of the patient you quoted is not based on her personal experience but is rather the product of the propaganda machine of the gigantic right wing in the health care debate — the health insurance industry, the AMA, big pharma, the Jackson Hole Group, hangers-on in academia, the Republican party, and a substantial number of Democrats who wish they were Republicans. This unholy alliance has drowned out competing explanations of the US health care crisis, to wit, that administrative costs and prices are excessive. This alliance claims that the health care system is expensive because patients want services they don’t need and because greedy doctors are eager to acquiesce to the demands of their dumb and/or gullible patients.

If the US is going to be forced to retain a market-based health insurance system, it is essential that the public be fooled into thinking that the primary cause of high costs is the consumption of an excessive volume of drugs and medical services, not the price of those drugs and medical services. If the public and law-makers can be fooled into thinking that the problem is primarily high volume rather than high price, they are more likely to be influenced by advocates of HMOs, MSAs, and defined-contribution schemes (e.g., Bush’s Medicare voucher plan). As long as the “volume is the problem” mantra reigns supreme, HMO advocates get to claim that someone has to do the dirty work of wiping out all those unnecessary services, and better to have HMOs do that than some government bureaucrat. And MSA and defined-contribution advocates get to claim that unnecessary services will be wiped out by “consumers” thinking twice about whether they actually need this or that service because now they have “first dollar exposure,” not “first dollar coverage.”

But if the public and law-makers understand that over-utilization of the health care system is minimal or atypical and perhaps more than offset by gross underuse, market advocates have a much tougher row to hoe. If overuse is atypical, HMO advocates have to admit their professed raison d’etre doesn’t exist, and MSA advocates have to give up pretending that MSAs will save money by cutting services and will instead have to peddle the implausible fantasy that MSAs will save money because patients will now be motivated to bargain with drug companies, hospital chains, and clinics for lower prices. The notion that the US health care system will enjoy substantial savings from patients driving hard bargains with drug companies, hospital chains, and clinics is too ludicrous for words.

Finally, I would like to offer the unfashionable view that the great brouhaha about drug advertising is a tempest in a teapot. Yes, drug advertising appears to be causing too many Americans to demand expensive drugs when less expensive drugs or no drugs at all would do. But total US health care costs in general, and drug costs in particular, were double those of the rest of the First World before the FDA gave the drug industry permission to do direct-to-consumer advertising, and they’re double now. The relative contribution that drug advertising makes to total health inflation is small, and the relative contribution it makes to the enormous disparity between US and rest-of-the-world health costs is very small compared to other factors, to wit, no drug price controls, no controls on provider expenditures, and a multiple-payer system with all its administrative costs.

The next time you hear a patient spouting HMO and right-wing theories of the health care crisis, I urge you to inform her she’s repeating speculative agitprop, not well established fact.

I leave town for a month in a few hours, so I won’t be able to respond to any brickbats or kudos. I wish everyone a cool remainder of the summer.

Kip Sullivan

Excerpt from a message dated 8/11/01:

<>

AMNews
August 20, 2001
by Cheryl Jackson

“Leaders at the Queen City Physicians Group in Cincinnati figured that if drug company representatives wanted to lavish their doctors with gifts, why not instead have the reps give something that would help the practice and its patients? Hence, the thought process that led to the 56-physician multispecialty group’s plan to charge $65 for a 10-minute visit to listen to a pitch from a drug company sales rep.”

Frank A. Reddick, M.D., chair of the AMA’s Council on Ethical and Judicial Affairs (CEJA):

“This is setting up a commercial relationship, and it might prove a refreshing approach in that it’s a straightforward transaction. Whatever the pharmaceutical reps would have you say about their role, their role is a commercial one.” “Putting it on a flatly commercial way to access the physicians might actually lead to fewer of the sort of concerns that CEJA or the AMA has about gifts to physicians and some things that really aren’t related to the physician’s practice, like taking them to the ballgame. It may prove the wave of the future.”

http://www.ama-assn.org/sci-pubs/amnews/pick_01/bil20820.htm

Comment: From an unrelated letter in the same edition of AMNews:

Herbert Rakatansky, M.D., immediate past chair of CEJA:

“There is clear evidence that acceptance of similar gifts from industry influences prescribing habits. Such gifts are prohibited by opinion 8.061. Doctors who accept such gifts maintain they are not so influenced. The literature suggests otherwise. It is desirable for physicians to avoid even the appearance of impropriety in these circumstances.”

The new chair of AMA’s CEJA could learn from the prior chair. Or is this another unfortunate misstep in the transformation of the AMA?

AMNews
August 20, 2001
by Cheryl Jackson

“Leaders at the Queen City Physicians Group in Cincinnati figured that if drug company representatives wanted to lavish their doctors with gifts, why not instead have the reps give something that would help the practice and its patients? Hence, the thought process that led to the 56-physician multispecialty group’s plan to charge $65 for a 10-minute visit to listen to a pitch from a drug company sales rep.”

Frank A. Reddick, M.D., chair of the AMA’s Council on Ethical and Judicial Affairs (CEJA):

“This is setting up a commercial relationship, and it might prove a refreshing approach in that it’s a straightforward transaction. Whatever the pharmaceutical reps would have you say about their role, their role is a commercial one.” “Putting it on a flatly commercial way to access the physicians might actually lead to fewer of the sort of concerns that CEJA or the AMA has about gifts to physicians and some things that really aren’t related to the physician’s practice, like taking them to the ballgame. It may prove the wave of the future.”

http://www.ama-assn.org/sci-pubs/amnews/pick_01/bil20820.htm

Comment: From an unrelated letter in the same edition of AMNews:

Herbert Rakatansky, M.D., immediate past chair of CEJA:

“There is clear evidence that acceptance of similar gifts from industry influences prescribing habits. Such gifts are prohibited by opinion 8.061. Doctors who accept such gifts maintain they are not so influenced. The literature suggests otherwise. It is desirable for physicians to avoid even the appearance of impropriety in these circumstances.”

The new chair of AMA’s CEJA could learn from the prior chair. Or is this another unfortunate misstep in the transformation of the AMA?

The Washington Post
August 11, 2001
by Juliet Eilperin

“Rep. Dan Burton (R-Ind.), chairman of the House Government Reform Committee, arranged for an unusual government-paid trip to Frankfurt and Bonn this week to investigate the German postal system. He is also visiting his wife, who is receiving medical care in Frankfurt, according to the congressman’s aides.”

http://www.washingtonpost.com/wp-dyn/articles/A61368-2001Aug10.html

Comment: This is a very difficult report on which to comment. Those of us that dedicate our lives to health care are always saddened to hear stories of serious medical problems that require extraordinary measures. Our first and overriding response is the deep concern that we have for Mrs. Burton and for her family that shares in the pain of her difficult challenges. Any comments that follow inevitably will be interpreted by some as being callous for having used this opportunity to posture politically, but the posturing is precisely on behalf our concerns about access to health care for everyone that faces similar difficulties.

On to the comments:

What rhetoric predominates today?

Examples:

American has the best health care in the world.

We must continue to support research by our technological and pharmaceutical firms that are providing us with the most advanced care available, no matter what the cost.

Everyone should have the same insurance that members of Congress have (FEHBP).

Medicare needs to be modernized, giving beneficiaries choice like the federal employees have with the FEHBP program.

We don’t want a government program of health care.

Etc., etc.

Most of those reading these comments recognize this rhetoric, and understand the policy issues that drive it. There are very serious problems with our health care system, especially in access and coverage in a system that is infamous for wasting our abundant resources. Our national policies continue to favor the entrepreneurial elements in the health care system while continuing to neglect the unmet needs of the people. Unfortunately, the rhetoric continues to drive the displacement of our national priorities, as if the unmet needs were merely a nebulous construct, rather than real needs of real people.

Back to the difficult part of this message. We need to look at the actions of Rep. Burton, a man who is now deeply and intimately involved with the real needs of a real person. This overriding issue makes it impossible to fault his actions. He is making the best decisions he can in a very difficult, trying situation. He has walked away from “the best health care system in the world” and gone to another country that offers some of the best care available. He has walked away from “the most advanced research and technology” to another nation that likewise has advanced research and technology. With FEHBP coverage, he has his choice of any care within the limitations of his plan, but he elects to go to a country that happens to assure that care is covered and accessible for essentially everyone, with virtually no restrictions on providers. At home, he continues to work with elements in our society that want to keep government out of our health care. Yet he accepts a government funded health plan, and even is not above accepting government transportation for a combined personal and quasi-government-business trip. Apparently Rep. Burton does want the government involved in health care when it is providing him and his loved ones with access and coverage.

Real people have real needs. None of our needs are met by rhetoric. In health care, they are met partly by our own personal efforts. But clearly most of us by ourselves can never assure that we can meet the financial demands of catastrophic illness, nor the public health protections that can be provided only on a population basis, nor the assurance that the health care infrastructure will be there when we need it, nor the assurance that our resources will not be frittered by Wall Street and by the technological and pharmaceutical firms that have their own priorities which they have placed higher than the public good. Real people with real needs can expect those needs to be met only with a combination of personal effort balanced with a public effort that places reality above rhetoric.

Uwe Reinhardt comments on Bob LeBow’s response:

“It is hard to argue with Bob. He is totally right.”

Repeating the concluding remarks of Bob LeBow’s response:

Our system seems to embrace the ideals of “personal responsibility” for the poor but “personal opportunity” for the rich. Community benefit? That would be socialism. So “personal opportunity,” with its double-digit inflation result, has set the tone for American health care. We can see that with the direction our system is taking, the poor and near-poor will be increasingly left out, priced out of the market, by the “opportunists” who will then continue to lecture the less well-off about “personal responsibility.”

Yes, we have created a monster, but some folks are more to blame than others.

The Washington Post
August 11, 2001
by Juliet Eilperin

“Rep. Dan Burton (R-Ind.), chairman of the House Government Reform Committee, arranged for an unusual government-paid trip to Frankfurt and Bonn this week to investigate the German postal system. He is also visiting his wife, who is receiving medical care in Frankfurt, according to the congressman’s aides.”

http://www.washingtonpost.com/wp-dyn/articles/A61368-2001Aug10.html

Comment: This is a very difficult report on which to comment. Those of us that dedicate our lives to health care are always saddened to hear stories of serious medical problems that require extraordinary measures. Our first and overriding response is the deep concern that we have for Mrs. Burton and for her family that shares in the pain of her difficult challenges. Any comments that follow inevitably will be interpreted by some as being callous for having used this opportunity to posture politically, but the posturing is precisely on behalf our concerns about access to health care for everyone that faces similar difficulties.

On to the comments:

What rhetoric predominates today?

Examples:

American has the best health care in the world.

We must continue to support research by our technological and pharmaceutical firms that are providing us with the most advanced care available, no matter what the cost.

Everyone should have the same insurance that members of Congress have (FEHBP).

Medicare needs to be modernized, giving beneficiaries choice like the federal employees have with the FEHBP program.

We don’t want a government program of health care.

Etc., etc.

Most of those reading these comments recognize this rhetoric, and understand the policy issues that drive it. There are very serious problems with our health care system, especially in access and coverage in a system that is infamous for wasting our abundant resources. Our national policies continue to favor the entrepreneurial elements in the health care system while continuing to neglect the unmet needs of the people. Unfortunately, the rhetoric continues to drive the displacement of our national priorities, as if the unmet needs were merely a nebulous construct, rather than real needs of real people.

Back to the difficult part of this message. We need to look at the actions of Rep. Burton, a man who is now deeply and intimately involved with the real needs of a real person. This overriding issue makes it impossible to fault his actions. He is making the best decisions he can in a very difficult, trying situation. He has walked away from “the best health care system in the world” and gone to another country that offers some of the best care available. He has walked away from “the most advanced research and technology” to another nation that likewise has advanced research and technology. With FEHBP coverage, he has his choice of any care within the limitations of his plan, but he elects to go to a country that happens to assure that care is covered and accessible for essentially everyone, with virtually no restrictions on providers. At home, he continues to work with elements in our society that want to keep government out of our health care. Yet he accepts a government funded health plan, and even is not above accepting government transportation for a combined personal and quasi-government-business trip. Apparently Rep. Burton does want the government involved in health care when it is providing him and his loved ones with access and coverage.

Real people have real needs. None of our needs are met by rhetoric. In health care, they are met partly by our own personal efforts. But clearly most of us by ourselves can never assure that we can meet the financial demands of catastrophic illness, nor the public health protections that can be provided only on a population basis, nor the assurance that the health care infrastructure will be there when we need it, nor the assurance that our resources will not be frittered by Wall Street and by the technological and pharmaceutical firms that have their own priorities which they have placed higher than the public good. Real people with real needs can expect those needs to be met only with a combination of personal effort balanced with a public effort that places reality above rhetoric.

Uwe Reinhardt comments on Bob LeBow’s response:

“It is hard to argue with Bob. He is totally right.”

Repeating the concluding remarks of Bob LeBow’s response:

Our system seems to embrace the ideals of “personal responsibility” for the poor but “personal opportunity” for the rich. Community benefit? That would be socialism. So “personal opportunity,” with its double-digit inflation result, has set the tone for American health care. We can see that with the direction our system is taking, the poor and near-poor will be increasingly left out, priced out of the market, by the “opportunists” who will then continue to lecture the less well-off about “personal responsibility.”

Yes, we have created a monster, but some folks are more to blame than others.

U.S. Department of Health and Human Services Agency for Healthcare Research and Quality
Evidence Report/Technology Assessment, Number 17 March, 2001

“It is estimated that over 45 million people in the United States have acne vulgaris…” “Coupled with loss of productivity and unemployment, the direct cost of acne may exceed $1 billion per year in the United States.”

Findings: * “The literature is extremely heterogeneous, severely limiting the number of meaningful conclusions…” * “Evidence for subpopulations is either not available or reported in such varied manner as to prevent meaningful integration.” * “Evidence for quality-of-life outcomes and cost is not available.” * “Of 250 comparisons, only 14 had evidence of level A.” (Level A = moderate to strong evidence of a clinically meaningful endpoint) * “The literature is not organized to differentiate responses to (different levels of) therapy.”

http://www.ahrq.gov/clinic/acnesum.htm

Comment: If we cannot evaluate the management of the most common medical disorders, how can we ever make decisions about the proper allocation of our resources? An integrated, information technology system that links together our entire health care system would move us much closer to a model that would more readily provide answers to these fundamental questions about health care and our health care resources. Yes, there is much more work to be done to refine the information technology tools that would enable this, but we are moving much closer to that reality. Some of the challenges are discussed in the publication, “Networking Health” published by the National Academy Press (http://www.nap.edu).

Attempts at integrating our fragmented health care system, as exemplified by the Healtheon model, have failed miserably, largely because of conflicting interests in the marketplace. The framework that would enable integration would be a universal system of publicly-administered health insurance. Through an integrated information technology system for health care, we could help to provide a basis for making rational decisions on where our health care dollars would be wisely spent, and avoid wasting them on ineffective services. We will never achieve high quality until we develop a health care structure that drives quality.