December 23rd, 2009
12:11 PM ET

Health care reform – summarizing your comments

By Dr. Sanjay Gupta
CNN Chief Medical Correspondent

Late last night, I finally finished reading the senate bill and the manager’s amendment. I will admit: it was tough to get through and took me back to my medical school days. At some point, I would love to know how many people have read it or understand it well enough to formulate a decision. That is not, however, where I want to go today.

Instead, I want to try and summarize the hundreds of blog comments I have received. It appears most people are in favor of addressing the access issues of the uninsured and the underinsured. Most seem to think that is a noble, worthwhile and perhaps even moral goal. The largest concerns seem to revolve around cost and concerns about the possibility of worse care.

More specifically, there were many comments about the increase in taxes necessary to pay for this. That will likely happen for a segment of the population making over a certain amount of money. That amount is still being debated. There is a plan to decrease Medicare spending by close to 500 billion over 10 years. Supporters say this will finally remove inefficiencies. Critics charge it will lead to worse care for seniors. There could be a tax on Cadillac health plans. If your plan costs more than $23,000 to cover your family – not what YOU pay, but the total cost of the policy, there will be a 40% excise tax on any amount over that $23,000 amount. No doubt, most agree it is going to cost a lot of money to insure 31 million more Americans.

One thing that hasn’t received as much attention is a term that could cause eye glaze, but is worth talking about.

Comparative effectiveness.

It is this idea that we pay too much for too little, and we should spend some time figuring out what really works with regard to health care. It is this idea that perhaps we over-test, over-prescribe and yes, perhaps perform too many procedures, and yet our health overall doesn’t reflect that higher overall spending.

It is this idea that if we spend some time really figuring out if knee surgery is in fact better than taking anti-inflammatories for arthritis, and to stop performing as many of these operations if it isn’t better. I am not picking on my orthopedic colleagues. The same can be said of operations in my specialty of neurosurgery, or really just about any aspect of our health care system. You may be surprised to know that we can’t always guarantee better health outcomes because more money was spent, a medication was prescribed or an operation was performed. The answer is not always that easy.

The rub is this: If comparative effectiveness data shows a particular procedure is not as effective as believed, it is possible insurance companies may be hesitant to cover it. Instead, you may get a letter stating the procedure is not warranted. Supporters of this will say this is a good strategy to reduce costs. Critics will use the R word: Rationing.

What do you think of comparative effectiveness? Does it have a place in this discussion? And, how do you think it will impact the physician – patient relationship?

soundoff (148 Responses)
  1. Richard

    I am concerned that mental health evaluations, and specifically, neuropsychological evaluations, will be deemed unnecessary because it is difficult to prove that they save medical dollars. However, these types of evaluations are necessary to a) diagnose cognitive and mental health problems, b) select appropriate interventions, rehabilitative therapies, and compensatory supports, c) provide input to schools about how to educate children with disabilities, and d) improve quality of life. It would be short sighted to limit access to these types of evaluations. However, it is unclear how a "comparative effectiveness" analysis would deal with this aspect of medical care.

    December 23, 2009 at 12:54 | Report abuse | Reply
  2. Bill

    Comparative effectiveness is great when looking at the finances, but crappy when looking at people. Since we are all different, different things work for different people. If it is all about cost, then sure, use it to find the most effective manner to treat people cheaply. But if this is truly about care, then leave all options on the table to give people a higher quality of life. I want people to be taken care of, but this doesn't feed the hungry, shelter the homeless, or take care of the true necessities in life. This plan just raises taxes and interferes with our free choice to deal with the doctor for what is best for us. Just my opinion, for what it is worth.

    December 23, 2009 at 13:55 | Report abuse | Reply
  3. Don W.

    If there are to be "effectiveness panels", they should be inside the insurance companies that are being asked to pay for the procedures, not in government. I suspect they already exist in one form or another. Their effect on the doctor-patient relationship is to replace it with a trilateral relationship of doctor, patient, and payer, and this is both unavoidable and appropriate when someone else is writing the checks. And this is the root of the problem! Only in health care do we have a model where most people don't bear the cost of the services they receive. Everywhere else, even where insurance exists, it exists to protect against catastrophe (my house caught fire), not against routine problems (my light bulb burned out) or even significant events (my dryer needs replacing). And where are costs spiraling faster than inflation?

    Put bluntly, government has no business - and no Constitutional authority - in this space. Even if you ignore that, the hybrid model of government-managed private industry has a poor track record in the USA. If we want government managing health care decisions, then we would probably get a better outcome with the government running the system outright; there are fewer palms to grease.

    But how can anyone believe this will be less expensive? Since when are governments good at controlling costs? Can anyone name ANY government process that isn't politicized? Different people will get rich with government calling the shots, but the "Louisiana Purchase" and its hundreds of counterparts should expose this bill for what it is: a naked power grab by elite politicians and their cronies, financed by us and our progeny for generations to come.

    December 23, 2009 at 13:56 | Report abuse | Reply
  4. Kay E Burch

    Well, I was certainly concerned when my annual pap smear and breast exam were not paid for.... Iam 73 and thought this was ridiculous. This made me worry about rationing. Whenever I have had a hopital proceedure the cost has been enormous way out of line Medicare paid only a small prortion, supplementa a bit.a great deal is charged because only a little is paid or there is some other insane reason. If I did not have insurance the bill would have financially destroyed me as they have so many people. The government is missing the point. Control the health care companies and big pharm and the suing lawyers. Many of my friends are suffering because of that riediculous donut hole and why was Big Pharm able to prevent drugs coming from Canada? You know Iam right

    December 23, 2009 at 14:03 | Report abuse | Reply
  5. Bryan Stanford

    Comparative effectiveness study sounds great.

    It shouldn't cost 1/100th of what this bill will cost.

    December 23, 2009 at 14:09 | Report abuse | Reply
  6. John

    I am deeply concerned with either the government or an insurance company coming between me and my doctor. It is one thing to use comparative effectiveness in the treatment area it is entirely different when that approach is used in the diagnosis stage. Many of our advances in combating cancer, for example, involve early detection. I would hate for a doctor to have a sheet that says 98% of the time this growth is benign, therefore, it is not cost effective to do a determinable test. That decision may sound great to an government or insurance company accountant but not for me, my wife or child.

    December 23, 2009 at 14:16 | Report abuse | Reply
  7. Janet Cooper

    Discussion is always good. The first discussion should be about comparative effectiveness and its benefits and limitations. Data lags scientific discovey, data can be manipulated. Medical politics and vested interests are difficult for the doctor on the front lines trying to treat sick patients. Those are drawbacks that immediately come to mind about comparative effectiveness. I was fortunate to have been treated by doctor who went beyond the "conventional" treatment for my disease. He did this at risk to his license. I got well. As did his other patients. How can this be reconciled?

    December 23, 2009 at 14:16 | Report abuse | Reply
  8. Todd

    Comparative Effectiveness is OBVIOUSLY the way to go.....Until it IMPACTS ME...........

    December 23, 2009 at 14:21 | Report abuse | Reply
  9. Dr. Gregg Garner, Medical Director

    In my job, I have been doing comparative effectiveness for years, in terms of approving treatment plans or not. Doing more than what equates to desirable outcomes just increases costs, and lower efficiency, which we cannot afford. Holding physicians to outcomes based analysis, nationally accepted guidelines, and medical standards can help achieve parity in care delivery. Accountable care organizations, plus tying outcomes to payment methodology combined with removing incentives for physicians to do more and more will go a long way toward controlling costs. Effective population and disease state management can help assure best care, with decreased costs from better outcomes, less complications, and taking care of issues before catastrophic consequences develop.

    December 23, 2009 at 14:24 | Report abuse | Reply
  10. RDS

    Comparative effectiveness should absolutely be part of the debate. Medicine should be based on sound scientific evidence. The so-called death panels are a good idea. There should be reasoned weighing of the costs and benefits of these procedures. We all should have access to good medical care but prolonging a life an extra month and spending hundreds of thousands of dollars does not seem like an effective use of limited health care funds.

    December 23, 2009 at 14:25 | Report abuse | Reply
  11. Natalia

    I think comparative effectiveness data is good to have. However, insurance companies should not be allowed to deny coverage because one treatment is less effective (in most cases) than another. The decision over which treatment to use should be between the doctor and patient. Not every patient is the same, and not every disease reacts/develops the exact same way. But having access to comparative effectiveness information for both doctors and patients should help everyone make better informed decisions. Especially considering the constant advances/breakthroughs/changes that doctors have to keep up with.

    December 23, 2009 at 14:27 | Report abuse | Reply
  12. Dr. B

    Comparative effectiveness is laudable. However, if there is an expectation by the patient that he or she should receive some service or procedure they will then feel either disappointed or as if their care is being rationed.

    The indemnity business model undermines patient satisfaction for controlling utilization. Money is taken from the patient for premiums prior to a service being rendered and is not returned to the patient as a dividend if they are cost conscious consumers. Therefore, the patient will be disappointed and disgruntled for not receiving something. This was the failure with the Clinton Managed Care plan, it pitted doctors against patients while the insurers reaped the windfall.

    If you fully fund HSA's for individuals paid out of the difference between high and low deductible insurance premiums currently paid to the insurers, HSA's/HDHP's will then become a neutral cash event for the patient and money will be shifted from the insurer to the patient. Then if the patients still wants that marginal procedure, it is their own HSA money that they are squandering. In this way the patients decide to control utilization internally (conservationism) rather than being told how to utilize (rationing)

    See the intelligenthsa.com

    December 23, 2009 at 14:29 | Report abuse | Reply
  13. Pat in TX

    comparative effectiveness = rationing. We are all doomed to a lower standard of healthcare. I am sad for America.

    December 23, 2009 at 14:30 | Report abuse | Reply
  14. Susan

    Yes, we need to have discussions about comparative effectiveness! The idea that bigger, better and more expensive is always good is ridiculous. I am self-employed and buy my own health insurance which amounts to major medical with a $5200 deductible. I do not want to be spending money on procedures unless I know that I am going to get a better outcome for my life-style! I am tired of hearing the cries of 'rationing' when anyone tries to have discussions about this. As if insurance companies don't currently ration!

    December 23, 2009 at 14:35 | Report abuse | Reply
  15. Renu

    As a pathologist I do find myself ordering a lot of ancillary tests (cytogenetics,molecular etc..) because with all the advances being made in medicine the definition of what is considered "standard of care" is fuzzy. A lot of these tests are added on in an attempt to avoid missing something vital, however, in most cases the findings are not useful. I guess the question is, should we overdo everything just so we do not miss that one case which is an exception or should we just go by reason or logic and risk missing a significant finding in one case. I know if it was one of my family members I would want everything possible done.

    December 23, 2009 at 14:37 | Report abuse | Reply
  16. Juan

    We could have it both ways. We could have a cheaper, basic insurance that will try to save costs by removing procedures that are not effective. But, in addition, individuals should be able to purchase a supplemental insurance that will cover all those extra procedures. That way, most people would be satisfied. Those who want health insurance at a lower cost will only pay for the basic insurance. Those who are willing to pay more to avoid "rationing", can get what they want too.

    December 23, 2009 at 14:45 | Report abuse | Reply
  17. ACinCincy

    Follow the money.

    December 23, 2009 at 14:59 | Report abuse | Reply
  18. speet

    Comparative effectiveness studies in theory are great...the issue of course is that we have very few well-done studies for many existing therapies (especially when looking at a spectrum of options), and doing these studies will take years if not decades. Also, who is going to do these studies and pay for them? they will cost billions of dollars and decades of work. It is a wonderful theory and may be helpful in years to come, but most therapies that we are using now cannot be held up to such scrutiny as the research is simply not there. Relying on this information to drive health care reform at this point is unrealistic.

    December 23, 2009 at 15:15 | Report abuse | Reply
  19. Mitch

    Doctors are paid on a per case basis, not on the outcome. This is where we must start to create the framework to establish comparative effectiveness Doctors should be paid based on the outcome of the patient care,establish a floor and expand payment from there. If it is effective then the doctor gets paid more, if its not and needs to try another approach then the Doctor is compensated at a minimum for the attempt. Too often doctors over treat because they earn more money. The patient is also at fault wanting "Nothing but the best", who defines the Best?

    December 23, 2009 at 15:15 | Report abuse | Reply
  20. benhur

    As a nurse, I am alarmed at the thought that a committee of budget-minded businessmen might challenge my physician's determination that a particular treatment or procedure is warranted.

    Health care providers know full-well that removing a clot from a brain in a 24 year old might have a different outcome than doing the same thing on a 90 year old. One has to consider the patient and his circumstances.

    Where is an individual's case-by-case consideration likely to have the most even-handed result? In the hands of the primary health care provider who is not compelled by a lack of "tort reform" to cover his or her own behind. Involving national-level governmental bodies in this sort of critical decision-making is fraught with danger. And frustration and anger. And innocent lives that slip through the cracks of that 2000 page proposal.

    I think we are making a huge, hasty mistake.

    December 23, 2009 at 15:17 | Report abuse | Reply
  21. Tom

    I am not a doctor and have no medical training. There are some things I know I can do to make my self healthier, but when it comes to anything more complicated than healthy diet, treating a headache, a cold or a fever, I have no choice but to trust my doctor. The only doctor I would trust is one who is informed on the latest procedures that have been documented to be effective through empirical study. I don't want a doctor to prescribe anything for me just because that's what he learned in medical school 30 years ago, or because some pharma company gave him a nice "consultant" fee, or because he otherwise has a finacial interest in what he prescribes. If an insurance company must be involved, I don't want it standing in my doctor's way of prescribing me the latest, most effective treatment as determined by science.

    December 23, 2009 at 15:17 | Report abuse | Reply
  22. Leslie Brown

    I have a unique perspective, I worked at Medicare as a claims examinrer for 4 years, I have been diagnosed with Parkinson's,I have a mentally ill daughter, and I care for her two children – who both have NF1 . . my few years in Medicare saw way too many over charges by physicians not knowing that the beneficiaries were seeking same services by mltiple doctors – and I mean millions of $$. I see very little done to help with mental health addressed in this current go round of health care reform..... I am concerned for my grandchildren, who will require multiple tests for years to come.. in the limiting of services, what would be the idea system?

    Can anyone tell me that.. not the quick fix... it's obvious that's only going to create a mess, then they will have to redo the mess for years to come.... can someone... please look at the years long issues... not the quick fix.

    December 23, 2009 at 15:18 | Report abuse | Reply
  23. Terri

    Very interested in seeing us try comparative effectiveness. But wonder how the system will account, first, for identified inequalities in treatments to women, people of color, and the poor. If we can overcome those moral and rational dilemma, then proceed while not exacerbating them, I am supportive of system-wide trials. Let's think and work together to improve our hc system for everyone.

    December 23, 2009 at 15:29 | Report abuse | Reply
  24. vic

    won't the system be immediately overrun/bankrupt by people who didn't have insurance and therefore didn't do certain procedures that weren't absolutely medically necessary

    but, now that THEY don't have to pay the cost of the procedure (only the cost of the insurance), all of a sudden they WILL want the operation (for example, an ALCS replacement might not be medically necessary, and therefore the person without insurance will not have it done - but, now that THEY aren't responsible for most of the cost, they'll INSIST on having the multi-thousand dollar operation done on somebody else's "dime" - and, since there is now going to be NO pre-existing condition clauses, that the bad knee is old doesn't matter

    also, the penalty for then DROPPING insurance after getting all their held-off voluntary conditions taken care of is virtually nothing (wow! $95 "penalty" after gettting THOUSANDS of dollars of medical care paid by somebody else

    so, the "invincibles" will have whatever procedures they wouldn't pay for themselves taken care of by "the system", then pay a MINIMAL penalty for dropping medical coverage - and they will continue to game the system, joining only when they have a condition that they don't want to pay for, then dropping when they don't want to continue paying for insurance

    December 23, 2009 at 15:36 | Report abuse | Reply
  25. Jane

    This is one of the best articles I've read on the subject.

    As a registered nurse, I would also like to add that there is enormous waste in hospitals as well. Hospital managers, who often understand little or nothing about the process of healing, have reduced their professional nurses to little more than assembly-line task performers. They hire numerous assistants to replace nurses, and to patients these assistants are not distinguishable on sight from nurses. Until hospitals begin providing truly professional nursing care to their patients by providing primary nursing and all-RN staffs, we can continue to expect countless avoidable complications in patients and countless lawsuits - not to mention countless burned out nurses.

    December 23, 2009 at 15:36 | Report abuse | Reply
  26. Charlie in CA

    Everyone is scared of "Rationing", "or Comparative effectivness" but health care is already rationed. If you have a good job with a good health care plan or enough money you get it, if not you you dont have a ration. how many of us WITH health care have had our insurance deny a procedure because it is not covered or is not proven as effective? Getting a standardized panel with Open meetings and access brings a bit more honesty to the process. Now if only we can stop the hype and fear and use reason. Currently we ARE rationed. There ARE "death panels" (for every insurance plan). If we use Comparative effectivness more, we may find cost savings in not only useless tests, but wasted medications as well.

    December 23, 2009 at 15:38 | Report abuse | Reply
  27. Tundra

    If we have choosen that the government is going to get involved in the payment aspect of medical care. Then yes they also have a responsibility to decide what is covered and what is not.

    December 23, 2009 at 15:50 | Report abuse | Reply
  28. Kathy

    unfortunately, "rationing" doesn't account for human variable. I am concerned that there is a gross misuse of healthcare funds and I see providers frequently pushing the ethical envelope. As a healthcare practitioner I have both seen it and been a victim of it. Unfortunately, ethical, quality care is not incentivised. What you get from the government is 21 page intakes, of which very little is relevant to the case, and such a long time awaiting approval that the clients loose ground making it impossible to show effectiveness! There are greedy money mongers who know how to push that envelope and steal a bunch of money and deliver poor care. It is unfortunate that greedy money mongers go into caring professions. But regulation has not stopped greed in banking or law and it won't stop the greedy in healthcare. It will only explain to them how to play the game. In government healthcare, everyone looses. The ideas are great, they just don't play out the way you think they sound. It is not about whether people should get what they need. The real question is how do we incentivise quality care and make it within reach? Raising taxes and cutting services, therefore jobs, will only add MORE people to the list of those in need!

    Why can't we have a GEICO of health insurance???

    December 23, 2009 at 15:52 | Report abuse | Reply
  29. P.J. Roberto, M.D.

    The problem with the current health care reform bill is that it does nothing to address two primary aspects of cost.

    The first is fraud – it is well known that medicare/medicaid fraud is one of the most lucrative crimes in the U.S. I've heard figures in the $60 billion range. It is truly difficult to discuss (or obtain public support for) any changes in health care without a substantial, well publicized effort to prevent fraud and to punish the offenders. This should be done in a manner that prevents legitimate health care providers without too many hastles in providing needed care.

    The second is the massive amount of waste. Much of this does occur at the end of life and in nursing home patients. This was addressed in a recent "60 Minutes" broadcast. Doing such things as providing dialysis for terminal cancer patients and extensive evaluations and treatments of nursing home patients for whom it is quite obvious there is no possibile benefit or change in quality of life is bankrupting our health care system. Educating the public about these issues and the costs of these treatments is critical in decreasing these unnecessary procedures, treatments, and costs.

    A statistic mentioned on the "60 Minutes" episode mentioned the fact that something like 85% of Americans want to die at home. The statistic that was missing was the number of people who would want to have a family member die in their home. Even in the health care community, watching a loved one die in your house is a very difficult thing. Americans have the expectation of going to sleep and never waking up. They don't consider the large number of patients who spend months and years with mental and physical deterioration.

    The bottom line is that we have to increase education about end of life issues. We need to accept that some patients are simply not candidates for some treatments. This is difficult if not impossible to legislate. These decisions need to be made by patients, families, and physicians. The comment, "do everything for my dad," needs to induce a compassionate, realistic response from the health care providers. As physicians, we need to realize that we cannot offer every treatment to every patient at all times. We need to use our knowledge to educate the patients and families about what is realistic.

    This sort of "reform" is more one of education than legislation. The legislative aspect of this comes in a restraint of the legal system. The comment, "do everything for my dad – or I'll sue you," is really what a lot of physicians hear when a family member talks to them.

    There needs to be legislation to allow physicians to not feel the constant burden of the legal system breathing down their necks every time they make a decision. In our current environment, it is much simpler and legally safer to order an expensive diagnostic test or treatment than to say, "that isn't necessary," and then if you are wrong you are facing a law suit.

    This, finally, brings me to the concept of "comparative effectiveness." Using clinical guidelines (sometimes mandated by the government) to evaluate patients has already become the norm. Most medical boards include knowledge of "clinical guidelines" in their board certification programs. The reality is that without legislation saying that if Dr. X can show that he followed the guidelines in treating patient Y he is immune from law suits, Dr. X is generally going to pick the more expensive, complex treatment – especially when the patient heard about it on the internet and really wants to have it done.

    In summary, we do need to look at where we are spending our health care dollars. Fraud obviously needs to be eliminated. Treatments which provide little or no benefit in quantitiy or quality of life need to be withheld. This is especially true for patients at the end of life or with no little or no quality of life in the first place. This does not mean that we need "death squads." We just need some education and rational discussion. If we address these areas of waste, we can then look at micromanaging the smaller health care decisions.

    December 23, 2009 at 16:03 | Report abuse | Reply
  30. JC

    comparative effectiveness absolutely has a place in the discussion. Not to ration, but to educate. Health care is at its core experimental, and both doctors and patients should have readily available, current information to be able to prioritize those experiments, starting with the most likely to succeed.

    Dr. Gupta, I'd like to see you address whether there is enough (or any) in this bill to promote and incent healthier living. Regardless of how we change the payment system, the vast majority of costs come from preventable conditions. We need an invesment in healthy living rather than investment in payment practices.

    December 23, 2009 at 16:08 | Report abuse | Reply
  31. M Dissanayake MD

    There is a much more less costly way of providing health INsurance to 30-40 million Americans who can't to day afford to buy health INsurance .

    My concept is based on Providing Tax breaks for the Health care providers who will provide services for the 30 million Americans uninsured. . In Place of monetary reimbursement The Government gives a Tax credit for the Providers for their services and allow Insurance plans to offer a low cost Health Insurance plan . The providers use their own revenues to provide service without loosing a cent but make 6.25% more than what they would have been paid.

    1) The Insurance premium for the said population costs 100 $ per month. If at least 20 Million population out of 30 get Insured this would be a 24 Billion Industry per year.
    2) The providers bill the Insurance plans and the approved amount by the Insurance companies will given as Tax credit by the government with 6.25% interest to the provider. The Insurance Companies pay the government only 6.25 % of the reimbursement they would have otherwise paid to providers ,which is again equals the 6.25% interest on the unpaid fees the provider would have otherwise received .
    3) The Tax credit is given only to Providers who opts to see patients under those low cost insurance plans and also only to the amount applicable for providing service to patients under low cost Insurance plans .
    4) The Government will tax 35% -40% from the Insurance Companies from every premium they sell to the 30-40 million uninsured they sell this low cost health insurance plans under this scheme, to cover the losses from revenues from Providers being given a Tax credit .
    5) This plan does not take years to start and does not require imposing higher taxes to public nor does it cost 800 billion.
    6) It creates close to 9 billion per year revenue to the government.

    M dissanayake MD

    December 23, 2009 at 16:18 | Report abuse | Reply
  32. Ashley

    Comparative analysis is a good idea to reduce costs in running a business – but humans are not machines or merchandise. The big brother cannot and should not dictate to a doctor whether or not a certain procedure is the 'right one' for an individual. We are all different and what may work for one person’s body, may not work for another's. This ploy by the government is simply rationing of care for everybody while increasing the cost which will be passed on to Americans in various methods. Instead of the government being involved in the equation, insurance companies must be able to compete with one another. More competition means lesser cost to consumers. It is unfortunate this bill is being passes even though majority of Americans oppose it.
    This is SAD!

    December 23, 2009 at 16:26 | Report abuse | Reply
  33. jj6x

    here is my question. Is the problem that health care has unnecessary treatments or is it that the pricing of these treatments is over inflated. I had a hospital try to charge me $200 for 2 aspirin that I didn't even get. Never mind that they were trying to charge me for something I didn't get. Why is the hospital charging $100 per aspirin when I can go to cvs and buy a whole bottle of them for $4? Hospitals can argue that they have to pay for the expensive equipment somehow but really, if you don't have the available budget to buy it in the first place then you really shouldn't have one. Secondly, this medical field mindset of keep then alive at all costs doesn't help hospital budgets either. When did we stop taking into account quality of life? If its gonna cost $300,000 a year to keep grandma on life support and she doesn't have it stashed away then let her go. Yes its painful to lose a loved one and she will be missed but everybody dies. its the one universal truth. quit acting like death is this horrible enemy. My grandmother was forced to waste away slowly long after her mind was completely gone. at some point the human body stops being the person you loved and starts just being the shell they occupied while they were truly alive.

    December 23, 2009 at 16:58 | Report abuse | Reply
  34. Chris

    Dr. Gupta,
    I am 53, a diabetic, and was hoping for either the public option or the Medicare buy in at age 55. I have insurance through my employer, but they are self-insured and restrict a lot of my medications through their "formulary" plan where a lot of my medications are not considered on the formulary so I have to pay a $50 co-pay on each one (for diabetic medications). Under Medicare, these medications would be covered.

    None of the Senators really considered those of us under a self-insured employer as we are trapped with no appeal of any denials for treatment.

    December 23, 2009 at 17:03 | Report abuse | Reply
  35. Jeff Watts

    If the government starts to ration healthcare and takes the decisions away for doctors and patients, then we are all doomed. I am worried that eventually, some govt entity will start to try to cut tests (to cut costs) based on "obscure or convenient" data.

    December 23, 2009 at 17:13 | Report abuse | Reply
  36. linda

    Hi, when i read many of these comments it is clear tome that the general population who critique this attempt at correcting our health care coverage issues have NO idea of what is reallyinvolved in the health care decisons that are made today. The government is making rules to help Save money not making individual decisions on health care. The general population has no idea that the insurance company is already determining what they will pay for in your care. They are not paying hospital for care rendered even if it is necassary and are denying "payment" under guises such as Delay in a pt making a decision or delay in a procedure when the physician only consutled and met the patient that day. I work for a hospital and I review medical charts and call the insurance company and they decide whether they will pay us or not.
    They get away with it under the guise of "payment" issue. I also see patients who are in hospitals an don't want to go home even thought they have meet no medical criteria. I could go on I really could It is so big it boggles my mind but I know it has to get correcged and I am tired of listening to the nay sayers who are telling me it isn't constitutional to mandate peeps have helath insurance.... then it isn't constitutional for me to pay for those who choose not to buy themselves coverage. Is it unconstitutional to mandate we all buy car insurance ? And yet that ia law.....

    December 23, 2009 at 17:15 | Report abuse | Reply
  37. Mohammad Huque

    Yes, comparative effictiveness idea is great. It can minimize waste. However, it needs to be implemented at the patient level. Patients often respond differently to different therapies and sometimes effects are unpredictable. Some may take a drug, and take the risk of its adverse everse events, but may not benefit form it at all. Much research and development are needed to figure out the effictivenssof drugs/ therapeis at the personal level. For example, which single or multiple gene trialts can be determinants for drug resposne in a patient. Once, we know this type of information and are able to select the most effective therapy for a patient in need, we can minimize the wastewful treatments and bring the cost of patient care down..

    December 23, 2009 at 17:26 | Report abuse | Reply
  38. Jessica

    Comparative Effectiveness is a subject that must be reserved for the physician and patient.

    It is too complex a subject to be left to insurance companies, though I trust an insurance company more than the US Government.

    Here's why. If I have a dispute with an insurance company, I have options available to me to resolve the dispute. Including assistance from state and federal government agencies if I believe my civil rights were violated, or the insurance company has acted in bad faith, committed fraud, etc. I also have the legal system.

    When the federal government is in control of my health care, including which procedures tests may be performed – I have no one to turn to.

    There are entire legal specialties devoted to representing people against the Federal Government in Social Security appeals, VA appeals. The policy of the feds is to deny deny deny – much worse than ANY insurance company.

    Medical care is essentially a private and confidential matter. Decisions on what route to take often involve more than the condition itself, but what the patient can tolerate in terms of missing work, family duties, or other challenges. There are too many variables, and depriving a patient and physician of the ability to tailor treatment to the individual, is something no one, including the federal government, has any right infringing upon.

    What concerns me greatly about this "reform", is that what is likely to happen is that Congress is going to treat my health care like their personal cookie jar. It's my life, my choices, and my business – not an opportunity for a politician to deny me a test, surgery or treatment that may improve my quality or life – or even save it.

    December 23, 2009 at 17:34 | Report abuse | Reply
  39. rick

    Wow... Let's start with a riddle. How do you eat an elephant? Answer: One bit at a time. The truth about this effort, much like almost everything else the government has ever done is that they try to do everything at once.
    Let's put it another way... No change that has ever been both worthwhile and lasting and also been both quick and bloodless. There's a choice, have a bloody coo over this (the irony of which is staggering), or take careful measured steps WITHOUT the typical wheeling and dealing. It's easy to hide behind cost fears when things like chemo-therapy and extensive surgey and expensive drugs are mandated.

    I know it will take longer, an many people will suffer in the meantime, but why not start with the basics. Certain annual check ups and well establish norms for everyone with a price tag everyone can agree on or at least quantify, and then let's go from there.

    If you try to eat the elephant all at once, all you get is sick and fat. How's that for irony?

    December 23, 2009 at 17:38 | Report abuse | Reply
  40. Taxpayer

    US pays 17% of GDP in healthcare now, BEFORE Obama spends another $Trillion. Compare this to many Euro countries with full coverage and socialized medicine at 8 and 9% of GDP. Two points: Obama taxes one class of workers to pay for others; and is doubling the deficit every year!
    IF Obama wants to provide healthcare to all, cut costs first, then expand coverage. This is socialism; tax working people to pay for expanding programs at outrageous long term costs with zero cost management system in place.The US tax system was established to provide for government, NOT wealth redistribution. Democrats are showing true colors as socialists. One person one vote is the law, though I question the millions of people who pay no taxes voting for programs that others must provide for them.

    December 23, 2009 at 17:50 | Report abuse | Reply
  41. Isaac

    My thinking is a medical decision should be made by the doctor and the patient concurring and that health insurance should stick to what they're supposed to do which is cover the patient's medical bills.

    If I'm paying for insurance and between the doctor and myself we determine surgery is the best option (and the particular procedure is not experimental or specifically excluded by the insurance ahead of time), the insurance should not have the right at that point to interject what is or is not necessary.

    December 23, 2009 at 17:51 | Report abuse | Reply
  42. C. Roeber

    I am a health care provider as an Advanced Practice Nurse. I have significant issues with "bean counting" which is the way a health care facilty will tpredict outcomes of care. In trying to satisfy "performance measures" and clinical reminders plus coding as a way to prove that we are doing what's required, we have taken away from the time we can spend with our patients. It feels like we are more concerned with how we look on paper than how the care is given.
    My facility has hired additional non clinician staff to track our measures. This drives up the cost and reduces the actual person to patient quality of care. Thanks for letting me sound off.

    December 23, 2009 at 18:05 | Report abuse | Reply
  43. Mark Soderstrom

    The comparative effectiveness question you failed to discuss is the comparative effectiveness of our health care system to that of other industrial countries. Our system consumes nearly twice as much of our gnp as the other countries yet our people are less health than those countries. Why don't any of the journalists discuss price controls on doctors, hospitals, and drug companies? Other countries have price controls, and they have better systems than we do. You ignore the truth. This tax on American business is killing our economy. It already almost killed GM. Health care is as much a cost of doing business as the price of steel. American business couldn't succeed if it was paying twice as much for all its other supplies. Why does anyone believe it will succeed when it is paying twice as much for health care? Where is true comparative effectiveness?

    December 23, 2009 at 18:08 | Report abuse | Reply
  44. Dulcie - Denver

    Wow, thanks for broaching the Comparative Effectiveness issue. It's a very interesting subject and I'm sure that it will continue to be a point of contention as health care is reformed.

    I think one place where Comparative Effectiveness needs to be examined is in the pharmaceutical area. Many drug companies create drugs that only provide marginal improvements (such as extended release formulations of medications that are approaching the expiration of their patent) of an already existing formulation. My insurance company (Kaiser Permanente) already limits access to these new drugs. However, I think one thing that would really improve matters is if drug companies were prohibited from advertising to prospective patients, urging them to ask their doctors for the newer drug. Many doctors will prescribe the new, more expensive drug to keep the patient happy even though it doesn't provide much additional benefit to the patient, driving up drug costs.

    However, the ugly side is that it could potentially limit access to orthopedic procedures that significantly improve quality of life. I believe that many insurance companies already review the need for invasive procedure.

    This interests me because I am currently recovering from hip replacement surgery performed 3 weeks ago. I'm only 51 years old, but I had to stop taking NSAIDS due to severe gastritis, leaving me effectively crippled by osteoarthritis. I'm very thankful that there was really never any question about me getting this surgery. I probably postponed it more than the insurance company did. However, I also benefited from electronic medical records that made my care extremely effective and efficient across an entire team of medical professionals.

    Above all, I want all Americans to have access to this level of care. I enjoy excellent health due to consultation with a very knowledgable and committed team of healthcare professionals

    December 23, 2009 at 18:16 | Report abuse | Reply
  45. Jeremy

    It is true that many procedures, tests and surgeries are performed needlessly. This is mainly to feed the incomes of physicians and practice groups, which are basically businesses. However, through epidemiologic investigation it is possible to determine which subset of patients WILL benefit from these procedures and give them to those patients accordingly. An example is cancer tumors-certain drugs don't work as well on some patients, and testing the tumor's biomarkers before treatment can predict which treatments are likely to work. Medical research is important to fund because it can find these breakthroughs and cost efficiencies in the process.

    December 23, 2009 at 18:18 | Report abuse | Reply
  46. WJC

    What many fail to observe is that most of this is already being done in the current private insurance sector. This is nothing new, rationing has been going on a long time, just look at your employer insurance options: Do you pick the high end insurance that covers more or the low end one that cost less but covers less. The problem is we have become dependant on insurance paying for everything we want. If the arguement is to be I don't want someone coming between me and my MD then why not just pay for it yourself. I bet if you had to make the decision between a $15k procedure out of your own pocket you might decide for yourself that it isn't needed. If it would truly change your life then you might sacrifice other things to get it done. The real question is who do you want making that decision? You can't have it both ways: No interference, but everything covered that you want. One of the first analogies used above was insurance for catastrophic coverage of your home, car, etc. They don't pay for car repairs or a lightbulb to be replaced. As Americans we need to grow up and learn that we can't have everything without a cost or paying the price somewhere and the insurance companies sure can't seem to control it either.

    December 23, 2009 at 18:22 | Report abuse | Reply
  47. rich

    I'm on the fence. I'm an emergency room RN. I see both sides daily. I marvel at the money spent to keep a 91 year old bedridden, contracted, (means her limbs are drying up do to not using them) demented pt. who is septic because she has a urinary catheter in place 24/7. She (or he) will spend weeks in ICU and if the infection is controlled, they'll be returned to the nursing home and we'll see them again in a month or two with a pneumonia and it'll all start over again until their system finally gives out and we can't do anything else. As a professional, I just treat and do what i'm trained to do. As a person, I think "wow, how many resources are we gonna use this time?" You can call it "comparative effectiveness". I think it's just common sense. We were all born to someday die. I think we've lost sight of that in this society.

    Now, on the other hand. The rampant WASTE of healthcare resources. Don't tell me we don't have free healthcare in this country. I have insurance paid by myself and my employer. I NEVER use it because of the deductible. (plus i'm pretty healthy) However, I see many people who are poor, but know the system. They can show up, state they have no insurance or ability to pay, and we treat them. If they have something serious enough to be admitted for, they're admitted. (I don't have a problem with that). However, the majority of these people are showing up for NOTHING. We have one woman who visits us 3xweek. One other man's chief complaint last week was "I have BM (bowel movement) in my pants!!" Of course he was drunk, but he getsa full medical work up and a bed. For free.

    OK, this may be starting to sound like a rant, but the point is, where does common sense in healthcare start and end? I've never been rationed, or had anyone i love be rationed, so i can't speak to that, but

    December 23, 2009 at 18:29 | Report abuse | Reply
  48. Mark Stevens

    I seek and accept jobs often of the basis of health care benefits. I do not want someone deciding for me if a physician may or may not perform a procedure simply because the cost/benefit analysis shows that only 31 percent of my fellow patients will receive relief. I want every chance at relief.

    This is an insult in addition to the time it will take for some local group of federal/state employees to get to my case and force me to die before the procedure is granted.

    All would be served by doing the obvious. Paying a bit less to providers (and making them take it) and letting them do their jobs.

    December 23, 2009 at 18:39 | Report abuse | Reply
  49. MediaGuru

    I think comparative effectiveness should be done by the medical professionals and not by the insurance companies.

    1) A minority of people on Medicare (or private insurance) seem to abuse the system by making too many visits to the doctor/hospital and having unnecessary procedures – maybe because they don't pay much of a per-treatment cost. Of course I would want nothing but the best care for everyone with legitimate health problems. However, I think one way to dissuade unnecessary treatment would be to require minimal co-insurance (co-insurance was forced on to my policy this year). I don't like it, but psychologically, it might dissuade wastefulness.
    2) Those of us to have insurance and pay our taxes have to cover the cost of the uninsured, the undocumented, and in some cases the low reimbursement rates from Medicare - while at the same time the money we're paying towards social security and medicare is likely going to be non-existant when my generation gets old. Requiring health insurance for all people seems most logical and fair. Why would we have this for auto insurance and not for health insurance?
    3) If your lifestyle increases your health risks significantly, then your insurance premiums should cost more, as you would have in any home or auto insurance policy. This would be hard to implement, but it seems most fair.
    4) We need to curb unnecessary testing for fear of malpractice law suits.
    5) Create more Federal grants for RX research so the drug companies can't use research as an excuse for charging sick people an arm and a leg for their medications.

    December 23, 2009 at 18:43 | Report abuse | Reply
  50. Steve C

    I think Comparative Effectiveness should be evaluated by every patient for every treatment being considered. The patient should then determine if the treatment is worth the cost and the patient should pay the cost. If you want to cut waste out of healthcare spending, have everyone pay their own bills. Buy whatever treatment you want. If you think people are entitled to options that they can't afford, take your money and give it to a charity that provides those services for people. I'm proud to support such a cause now. If this plan becomes law, only the wealthy will have good healthcare as they can purchase it outright. Our hospitals are already full of Brits and Canadians who come here with travel insurance and "suddenly have critical health issues". The government doesn't do anything well. Why would we entrust them with our health?

    December 23, 2009 at 18:50 | Report abuse | Reply
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