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. Moki in Tucson

    Few things have polarized this country as much as this effort at Health Care Reform. There is so much hysteria and anger coming from all sides it is literally making me sick! And I don't have Health Insurance . . . not because I can't afford it, but because I cannot get it for pre-existing health conditions.

    Between myself and my wife we spend between $15,000 and $20,000 every year for health care and have done that for almost 10 years. Presently, we own no property, have nothing set aside for retirement and not much savings to speak of. To add insult to injury, as non-insured we pay almost double what insurance companies pay for doctor bills, lab work, prescriptions, etc. To the insurance company, this is a volume discount. To me, it is discrimination against the uninsured.

    I'm very happy to pay the premiums if I can get the insurance without pre-existing exclusions.

    December 23, 2009 at 18:55 | Report abuse | Reply
  2. Sid

    As a former Canadian it still stuns me that the lawmakers refuse to see that it costs almost 3 times as much in expense per patient in the USA as in other Western Countries with one payer systems. They do work.

    And as long as you have insurance companies involved, the welfare of the shareholders of the company will always come before the welfare of the patients. The company seek return on investment and that is accomplished by either increasing revenue (premiums) or decreasing costs (refusing more and more patient treatment).

    We have a wonderful opportunity to take the best of what other countries have made work and build a fresh new system. It saddens me that special interest lobbying can be so effective that in realty the good of the people is really last on the priority list.

    Stop denying that it does not work in Canada, Australia, Britain, France etc. The solution is available and for much less cost than keeping insurance companies running the system. Shame on the lawmakers who deny this in favor of special deals.

    December 23, 2009 at 19:09 | Report abuse | Reply
  3. Stan Chraminski

    Let's face it. A profit motivated system will always ration care. Ever read your health insurance contract. The stupid comments, I believe in patient choice, are just platitudes. Even those in an employer plan must choose from available options. The only true choice is if you are rich enough to buy whatever care you need. Those in civilized countries don' t worry about going bankrupt from medical problems. Nor is the quality of care any worse. How can we say the system is not rationed when multi-millions have no health insurance. They are rationed by finances and die of advanced conditions because they couldn't see a doctor early enough. Comparative effectiveness if just one part that must be implemented to control costs. The others are "death panels" to see how much we can spend in the last months of life. We tend to deny we will ever die in this country and never even want to talk about it. Praying we will live forever won't hack it. While we're at it, we need to kick people's asses to get off them and exercise a little. That's one way to prevent most of the chronic conditions that run up the health insurance bill. We reap what we sow and we are sowing poor health through our bad habits. You'd think staying healthy would be its own reward but who ever said humans were rational? We don't have to worry though. On the path we are on there are only a few years left until we self-destruct and are replaced by a smarter species.

    December 23, 2009 at 19:10 | Report abuse | Reply
  4. Dial from SoCal

    The same Senators that are so busy patting themselves on the back are not going to be affected by Health Care Reform–they will make sure of that! The rest of us will deal with long waits for appointments and less effective care–not to mention higher taxes.

    December 23, 2009 at 19:13 | Report abuse | Reply
  5. Steve

    It is a shame that we have reached the 21st century and we cannot organize insurance. Whether that's health or car or life insurance the principle is the same.
    All of us (or all who want to be mebers of an organized society) put a small amount aside, so that when rare misfortunes hit a few of us, the resources are available to deal with it.

    This is money that belongs to us. Why do we need intermediaries (i.e. insurances companies) to "manage" our money or to decide whether we can use it or not, represents an insult to our intelligence. Why do we need insurance executives to run it for us?

    Unfortuantely, this process has been turned into an opportunity for the rich to get richer and for the poor to be supressed even more. Healthcare in particular represents an "inflexible" need. Someone who is ill and in need of it is completely dependent on the individuals who are in hold of healthcare resources.

    December 23, 2009 at 20:27 | Report abuse | Reply
  6. JB Sullivan MD MBA

    The only condition that would cause worse health care in America is to not achieve health care reform. I cannot understand why any reasonable person would oppose either the House or senate version of health reform. Fear is a powerful, conservative emotion.

    December 23, 2009 at 20:42 | Report abuse | Reply
  7. Steve

    I have been a democrat from the start and happily voted for Obama. While I agree that something needs to be done to limit the rising costs of healthcare I feel that this is being pushed through too quickly without much thought at all. The minute that government touches anything it destroys it. While to all the millions of people that think this is a "noble" cause they miss the fact that there are so many loopholes through this patch job bill that it has the potential to bankrupt our economy. I am sadly disillusioned with what my expectations were for this administration. Unfortunately many republicans were not too far off when they warned that this administration had it's own shady agenda to fulfill. Barring a Palin ticket I will be reluctantly be voting Republican next term since my representation who seemed so torn as to whether they should side with the president has all of the sudden through under the table dealings, agreed to this bill. Hopefully the Republicans can stop war mongering and fix our country instead of trying to fix other countries.

    December 23, 2009 at 21:23 | Report abuse | Reply
  8. Don

    We already have rationing. It's just not out in the open in a way that people identify it as such. I do not trust a for-profit company to ration my health care. Their motivation is not compatible with mine. I would prefer a doctor or health professional group make those decisions – not insurance company or politician.

    December 23, 2009 at 21:40 | Report abuse | Reply
  9. steve

    This is more of the nonsense that has so many folks so infuriated with our government. Comparative effectiveness could be good but should be determined by the medical community, not a government with a habit of ineptitude and corruption or vested interests such as insurance companies. Theoretically, comparative effectiveness is what medical researchers do, at least in part. These same doctors generally then teach medical students how to best practice medicine. Doctors also learn comparative effectiveness during internships and residency. Practicing doctors are expected to keep abreast of the latest medical findings. At least this is how it should work.

    When doctor's training and continuing education happens as described above, what makes bureaucrats better-able to determine course of diagnosis and treatment than the doctor who is seeing the patient? Nothing!!!!! We need to let competent doctors do what they went to med school to learn.

    While it's true that all doctors don't learn equally well and some have no business practicing, the medical community should weed them out and deal with it on a case by case basis rather than bureaucrats telling all doctors how to practice medicine.

    Time will tell how it will effect the doctor-patient relationship.

    December 23, 2009 at 21:44 | Report abuse | Reply
  10. Robert

    Is everyone entitled to the latest and greatest treatment for what ever ails them? Should society have to pay for the people that abuse their bodies with drugs, alcohol or tabacco or acts recklessly in some other way? If you were dying of cancer and you had to choose between living two months longer or leaving an inheritance to your children wouldn't you think about it differently.

    Insurance should provide preventitive care and basic proven care, not everything for everybody. Doesn't anybody understand that's what has driven health costs where they are, that and the six figure liability premiums every doctor pays. This country is stuck on stupid (especially congress).

    December 23, 2009 at 22:05 | Report abuse | Reply
  11. Julie

    I think we should do what the Germans do. They have socialized medicine that is similar to this idea. It covers "necessary care". To give you an example... if you get in a car accident, you will get the care you need to save your life. But they are not exactly delicate about it... they aren't concerned so much with the kind of scar it will leave as long as you are sewn up. Thats where supplemental insurance comes in. It pays for the "extra" services, such as plastic surgery or expensive/ experimental procedures that are above and beyond what your insurance will approve. It seems to work well there.

    December 23, 2009 at 22:19 | Report abuse | Reply
  12. Mik

    I have been a critical care/neonate heart-lung transplant/ED/ICU RN for 18 years and now I do Legal Medical Consulting and Disease Management.. I've worked from UCLA to 356 miles north of the Arctic Circle and all across our Nation. Comparative effectiveness...yeah, sure. The bottom line is none of what they are legislating is going to make a difference until you take out the profit. That would mean the insurance companies, the Hospital Industry itself and the privateness of it all. Doesn't matter how many studies you do, how many sub-committee's are formed, how many laws you make, if we are not accountable to eachother as a human race and yes that means saying "No" sometimes then we are going to have to realize that we are damning ourselves and our future of healthcare.

    As for the "R" word...I distinctly remember over 25 years ago the American populous was doing the same whining "they're going to come between you and your doctor"...what happened then? Ohhh yeah, HMO's! Seriously folks, you've had you're care "Rationed" to the hilt by the "private HMO's" for years...How quickly we forget.

    December 23, 2009 at 22:30 | Report abuse | Reply
  13. Nick

    The sad fact is that for large percentage of people, the cost of end-of-life care will exceed the total amount of money they earned over their lifetimes. How can a society afford to literally bury the wealth of future generations in the ground to rot? You people talk of "rationing" as if you have some constitutional right to every possible treatment no matter what the cost. The truth is that society cannot afford this and in the far future, if not confronted, will turn the US into a third world country where this won't be an issue since you'll be struggling just to feed yourselves. Unfortunately, this whole country is now populated with people that feel entitled to everything no matter who has to pay for it as long as it isn't them doing the paying.

    December 23, 2009 at 22:44 | Report abuse | Reply

    Shortage of Primary Care Physicians....
    My granddaughter yearns to become a primary care md....graduated cum laude from college; is working off her debt. She longs to become a GP but lacks a rich parent to put her thru med school. Why do we not provide such eager and capable young people with the opportunity to train?

    December 23, 2009 at 23:32 | Report abuse | Reply
  15. Peggy

    Comparative effectiveness is such a general term. Specialists, if they are good, should recommend the procedure given factors that warrant it. So the details of the information gathered to make an evaluation is critical for the decision. The decision should be make by the doctor not by the insurance companies' doctors.

    December 23, 2009 at 23:52 | Report abuse | Reply
  16. patti

    As an RN I am very concerned about this health bill. I don't trust the same government that allowed millions to be paid for senate votes and sweetheart deals to administer health care dictates from a comparative effectiveness board. We have already received notices regarding cuts in medicare reimbursement, rationing is on the way. In Canada don't they base care on "QALYS" or quality adjusted life years? Those dictates come from government boards.
    I would like Dr. Gupta to discuss his thoughts on the money included in this bill for such things as organic gardening, labels on vending machines for calorie counts, etc....Let's take care of sick folks first. The overuse of ERs will be a huge problem due to the lack of docs. The shortage will continue to worsen if they are reimbursed at Medicare rates.
    2000 pages of government bureaucracy never made anything better for Americans.

    December 24, 2009 at 00:04 | Report abuse | Reply
  17. Sherri S.

    The solution to the shortage of medical doctors is to train and support mid-level practitioners. Simple things can be handled be the nurse practitioner or physician assistant. referals can be made to specialists or general practioners that can work a patient up for the bigger problems. Priliminary testing can be ordered prior to the physician seeing the patient, expiditing the time it takes in the physician's office. Midlevels are also geared more towards the education of patients. This above all is the first step in generating a healthier society. Please pass this along to those that could make it easier for mid-levels to help with this health care crisis.

    December 24, 2009 at 00:15 | Report abuse | Reply
  18. George Fulmore

    I had what turned out to be a gallbladder attack. It was painful. I had to go to the emergency room to get a strong painkiller to stop the pain. Afterwords, I was given information about what my chances were to have more attacks and what lifestyle changes I could make to avoid them. In some areas of the country, under some fee for services health plans, I'm sure that I would have had strong advice to do surgery right then. Two years later, I have not had another attack. That is comparative effectiveness. That is an example of how money can be saved on health care services.
    I'm strongly in favor of health care reform. I want as many of the 50 million in our country without health insurance to have it. I'm on Medicare and I do NOT expect a reduction in my services as a result of the passage of health care reform.
    I continue to be a very strong fan of President Obama.

    December 24, 2009 at 00:34 | Report abuse | Reply
  19. lydia watters

    I am totally behind our president. However For such an intelligent man, it boggles me that he fails to see the real culprit. I am a hardworking PTA. who has been in health care for twenty seven years.I went through Clinton's HEALTH CARE REFORM! Insurance companies run our nation, Insurance co. mandate cost for Rx's MD payments. Hosp. rates Diagnostic payments, & much more as you know. Americans are INSURANCE POOR! I have found through first hand experience, their is always a battle to have them pay for your loss when needed! Where is all the money? I do know that lobbyist get a huge chunk Pharmaceutical Co's Very Huge .We need to monitor abuse of all these areas trained people to police them Government should have a well trained agency . Police crimes against law abiding tax payers of the UNITED STATES OF AMERICA.

    December 24, 2009 at 00:37 | Report abuse | Reply
  20. Jim Paradis

    The problem is this: "comparative effectiveness" is a *statistical* measure of effectiveness, whereas healthcare decisions are made on an *individual* level. There will always be statistical outliers, and these are the ones who will be most affected if comparative effectiveness guidelines are applied to individual cases. Here's an example from the present day: I know more than one person who respond very differently to generic versions of drugs versus brand-name versions. In theory, generics and brand-name drugs should behave identically because they contain identical active ingredients... but such things as fillers and binders can actually affect drug delivery and cause different results in certain patients. One such person just got a letter from the insurance company stating that they would only cover the generic unless they got a declaration of "medical necessity" from the doctor (hoop #1 to jump through). Having cleared that hurdle, they will only cover the brand-name at the highest permissible copay rate (which is not inconsiderable).

    In my opinion, "comparative effectiveness" is a very useful tool in medical research and should be used to inform doctors' decisions when selecting procedures and treatments, but it's dangerous for insurers to attempt to apply to individual cases.

    December 24, 2009 at 01:59 | Report abuse | Reply
  21. pete y.

    Comparative effectiveness implies several things: first, it implies that there is truly a dichotomous answer - that one treatment is better than another. This is not always true. Sometimes two treatments are equivalent. Sometimes "better" is in the eye of the beholder - i.e., quality of life versus quantity of life. Second, it implies that research could actually determine this. Again, for practical and ethical reasons, this is not always possible. Third, it implies that research would even be conducted. Unfortunately, research today is driven usually not by comparative effectiveness but by profit. So even if research could be done to this end, who is going to pay for it? It certainly isn't pharma, nor would it be the limited funds in the NIH etc. Fourth, what happens when technology and medicine changes? Are we to repeat each and every comparison test whenever things change? Fifth, comparative effectiveness implies that doing the right thing always leads to the right outcome. . . and unfortunately medicine doesn't work that way. Even if you do the absolute right thing. . . the unexpected can happen. While I support comparative effectiveness and its related counterpart – evidence based medicine, I think that there needs to be a healthy respect for "the art of medicine" – and that respect has to translate to 1. freedom for doctors to make decisions separate from guidelines and algorithms and 2. separate from medico-legal ramifications 3. separate from reimbursement of doctors. Remember, you get what you pay for in this world.

    December 24, 2009 at 02:14 | Report abuse | Reply
  22. Carol

    I am not hearing anything about using advanced practice nurses to provide primary care. I just listened to a report about the lack of primary care physicians to meet the demand of more people seeking health care. There was nothing in that report about advanced practice nurses filling that role. There is a strong health promotion and patient education component in nursing education. That is going to be an important part in keeping health care costs down.

    December 24, 2009 at 02:39 | Report abuse | Reply
  23. Robert SF

    But by any other name, comparative effectiveness is already practiced by insurance companies, at least from the patient's point of view. What does comparative effectiveness mean to the patient? It means that the patient might ask for something that will be denied. Well, insurance companies already do that, and the practice was one of the big reasons why Americans supported and even demanded healthcare reform.

    December 24, 2009 at 03:26 | Report abuse | Reply
  24. J.V.Hodgson

    The answer to the "comparative effectiveness" conundrum lies in part in another blog about "family doctors". Where I was born the state ran health care its premise was that you must have a primary care physician, and when you move for whatever reason and go to another Primary care physician his job is to ask for your previous one and obtain you records. These used to be written files but are now of course all computerised. Other than in the case of emergencies (and even then) the first question is who is your family doctor, that gives them access to your birth to now key medical history items. This aids tests to be done, not done, allergies previous dieases, surgeries etc., armed with access to that data I guess some decisions become easier and clearer as discussions on that may have occurred already with the Family physician who can be called by any specialist. If as is often the case the family physician refers you to a specialist, he does so and sends the patient file to the Hospital specialist so he can review before seeing the patient, and if there are any doubts he can talk with Family doctor before finalising treatment.
    This factor is for sure a reason why big savings can be made in American health care.
    I am appalled at the fact a specialist can earn 4 times as much as the family physician. The system that allowed that to happen is a disgrace.

    December 24, 2009 at 03:52 | Report abuse | Reply
  25. John

    I would be surprised if insurance companies with good actuaries would change their mind based on the numbers cited. A large company would already have reliable figures for cost analysis. Most of the cost of screening mammography is offset by the reduction of cost of treatment of numbers of fatal breast cancer. Only the government would shoot themselves in the foot to save upfront costs.

    The traditional cost-effectiveness analysis would subtract the costs saved by fewer breast cancer deaths from the costs of screening. The efficient frontier analysis incorporates no such adjustment. A traditional cost-effectiveness analysis was actually included in an appendix of the supporting evidence paper listed on the USPSTF website.

    December 24, 2009 at 04:43 | Report abuse | Reply
  26. Dr. F

    Health care reform will not be achieved unless we remove the obstacles that make care costly and expensive. Those that work in the current health care system are faced with these challenges on a regular basis. The factors that drive up costs include defensive medicine secondary to the malpractice crisis. Excessive paperwork and documentation requirements that cut into time spent with patient care. Lack of adequate preventative care which leads to people getting costlier treatment once a condition becomes more advanced. Cost are driven up by peoples life style choices including smoking, substance abuse and lack of proper diet and excercise. Costs are diven up when those patients with chronic conditions such as diabetes, hypertension and kidney disease do not get proper primary care. Health care reform is not focused on improving patient care but instead reducing costs and payments to health care providers and institutions. With less funding for health care will ultimately force rationing of services and less access to diagnostic and specialty care and procedures.

    December 24, 2009 at 04:57 | Report abuse | Reply
  27. Naren Patel

    Who is going to pay for this Health care or are we going to
    BORROW some more money from China which our children and grand children’s have to pay back with INTREST and also take some money from the Medicare’s and Medicaid’s that is already going broke.

    December 24, 2009 at 09:32 | Report abuse | Reply
  28. Pathologist

    Today is a sad day for the freedom of America. My great-grandparents came over here in here through Ellis Island in the late 1800s-early 1900s. They came over for an opportunity to make a better life for themselves by having freedoms from destructive governments in Europe and for opportunities to do business in America.

    As a physician in training, I find myself ordering over $100,000 worth of tests on patients, with end stage AIDS, renal disease, CNS lymphoma everyday because my bosses are too scared to just let these people die.

    Medicine is no longer an art. It is merely a business. And since our liberal federal government has no problem destroying our economy and destroying the greenback by ruthless spending, it makes sense that doctors should order needless tests in order to take money into their practices.

    More than 50% of healthcare dollars are spent on patient's last 6 months of life. If families were told that they had to bear the entire cost (which they should), they would gladly let their love ones move on to the next world.

    Don't get me started on the entire illegal immigrant thing. Do you realize how many people are going to risk their lives trying to cross into this country to get free healthcare that we hard workers, whose parents worked for hard for and will now have pay for?

    It's unfortunate that people voted for the what is now the worst president this country has ever seen. He can't run a war. He can't fix an economy. And he will ruin healthcare by adding more government into people's lives and by destroying the doctor patient relationship.

    I think our ancestors would be sad to see that they passed on a world of needless bureaucracy and government, that which they risked their lives to escape.

    It's unfortunate that we are so politically correct, that our leaders truly believe that if you don't work you should deserve handouts, and that if you do work, you are forced to pay for others handouts. We used to have a country based on good deeds and philanthropy, but now that donations will be taxed into the ground, people will be less reluctant to help.

    December 24, 2009 at 09:38 | Report abuse | Reply
  29. Danni N.

    Comparative Effectiveness is based on the analysis of data. I analyze large amounts of data for a living. I guarantee you, data can be interpreted a wide variety of ways, all of which are correct. For example, as a whole the data may show that a certain procedure only works in 30% of the cases. But upon deeper analysis, it shows that if you remove smokers from the data base, the procedure works in 50% of the cases. Further digging into the data shows that when conducted within the first three months of symptoms, the procedure works in 75% of the cases when performed by experienced surgeons, but in only 50% of the cases when performed by inexperienced surgeons. Also, certain medications improve the outcome of the surgery when taken at certain times and the underlying health of the patient is influences the outcome greatly. Measuring the outcome is ambiguous also. What is considered success? 50% rehabilitation is considered success but not 45%? AND, it takes weeks of studying the data, rebalancing the panel, doing "breakouts" of various sub-groups, and deeply looking for insights' and the data analysis must be done by someone deeply familiar with the topic. Furthermore, with most data, not everything is known....the age of the patients may be unknown, their existing health condition my be unknown, etc. making impossible to do the necessary analysis, and forcing reliance on the just the "toplines". And even very large studies can be interpreted many ways; consider the HRT study of several years ago. So,in many, many cases, it is impossible, to draw accurate conclusions from the data that are simple enough to be useful.

    December 24, 2009 at 09:43 | Report abuse | Reply
  30. Dennis

    If you really want to PAY for this With Ease and Save many Lives in the process then I say TAX ALCOHOL As you do SMOKERS....With Alcohol costing this Nation in Medical and Other SERIOUS costs at A Whopping amount of $ 175,000,000,000.00 a YEAR for ITS USE,One would figure This Upside Down SOCIETY would TAX this POISON Like they DO SMOKERS ,who By the WAY only harm THEMSELVES (MAYBE)..What i mean is You can NOW buy a SIX pack of BEER Cheaper than a PACK OF CIGARETTES..And the ALCOHOL is In FACT for REAL,The REAL CAUSE of all the ILLS in AMERICA,It Affects everyone that GETS IN ITS PATH and the FUNNY PART IS this:It is CONDONED and SAID to be GOOD FOR YOUR HEALTH,The Biggest Lie Since The PASSIVE SMOKE LIE.Now With California Selling 14 Billion Drinks a Year ok,Lets say a HEALTH TAX of 2.00 Per drink,shot,bottle,kegs,can.mixed drink.....And WALLA ? Now Seeings that SMokers pay 3.00 Per PACK TAX and thats Ok ,when in Fact they dont even come close in Health care Costs That ALCOHOL DOES.............Good IDEA ?????? naaaaaaaaaaaaa They Are too Big to TACKLE and the CLYDESDALES would GET SICK

    December 24, 2009 at 09:47 | Report abuse | Reply
  31. Pat

    I've been watching your health care debate with great interest. I can't believe that the majority of Americans are against health care reform. Half my family are Americans and they are all for it. I think the pollsters are asking the wrong people. Get out on the streets and into areas where people can't even afford phones. As a Canadian of 70+ years I have not had one minute of concern for my health care in my entire life! As a senior, I pay $100 a year for my few meds plus $4.11 dispensing fee. In the province of Ontario, families are now assessed $250.00 app. to help towards their free coverage. Socialism is not a dirty word. Of course we pay higher taxes based on income but I've never heard of anyone losing their home because of health care costs. Take heart and be positive about your governments decisions. You deserve this reform.

    December 24, 2009 at 09:53 | Report abuse | Reply
  32. Dennis

    The economic impact of drug and alcohol use is a staggering $43 billion dollars a year according to the Florida Alcohol and Drug Abuse Association. This November 11th Florida's leading organizations on substance abuse made the announcement at a press conference in Tallahassee. ABC 27's Abbey Phillips finds out who's most at risk, and how state leaders hope to curb the appeal.

    Drug and alcohol abuse are problems that affect almost every household nationwide.

    “Nowadays if you go in a room with 10 people, say does someone know someone in their family who has been severely impacted by addiction to drugs or alcohol, you will get at least four or five hands,” says Bruce Grant, dir., Florida Office of Drug Control.

    But now, a new report shows the economic impact of drug and alcohol use in Florida.

    “Billion dollars totally, annually, per year, and that affects not only family budgets, but state budgets,” says Ellen Piekalkiewicz, Fl. Substance Abuse & Mental Health Corp.

    Florida's substance abuse organizational leaders say the consequences of drug and alcohol related injuries, hospitalizations and crimes will cost Floridians nearly five million dollar every hour.

    “In the Department of Corrections we have community drug treatment beds that keep people from going into a prison commitment at a much greater cost and those have been cut 45 percent the last two years,” said Mark Fontaine, Fed. Alcohol and Drug Abuse Assoc.

    December 24, 2009 at 09:55 | Report abuse | Reply
  33. Lou

    Comparative effectiveness: just another way of our insurance to play doctor. We hated it with our insurance carriers and now the government thinks it can do better. They should stick with the post office, police and fire departments - that's where the govenment does socialism well. Insurance reform is what we need, not a government-based health care managemente system. Give money to the hospitals to set up health care centers for the poor and restrict private insurance carriers to profit margins. Next thing you know, congress will want to manage our family holiday parties!

    December 24, 2009 at 10:05 | Report abuse | Reply
  34. John

    Most American actually favor most of the Health Insurance Reforms in the proposed bills. The anxiety, fear, anger, etc. is on the question; how will the cost be paid for and how will it impact my healthcare. The proposed bills provide some detail (on the tax side) on how the cost will be paid for. However, and must importantly, the bills simply say we will cut $500 billion dollars out of Medicare and make other ambiguous provisions. It sort of like going to a builder and telling him to build you a $872 billion house and he gives you few real details and tells you to trust him you will like it. I know this post is not on point for this Board, but my point is some of us are for Healthcare Reform but not reform that is undefined. And further, reform that ultimately will be shaped behind close doors in Washington.

    December 24, 2009 at 10:17 | Report abuse | Reply
  35. Manuel J.

    Does it really matter what I think? Afterall, this Congress is in a rush to meet a deadline rather than provide a real solution to this issue. No, we'll have another version of a broken system, when all is said and done.

    December 24, 2009 at 10:19 | Report abuse | Reply
  36. S. Agha MD

    The real question is not whether conservative therapy is better or invasive procedures better. No study can conclusively prove this, as a perfect study will be needed for each and every organ system, subcategarized by gender, age, race etc. add to that all researchers have their own bias.
    The majority of physicians know when arthroscopy is necessary and when an anti-iflammatory will do.
    The real questions is what drives this unnecessary testing and treating??? Answer: Defensive Medicine. and who did we put in charge of "fixing" the healthcare system......a bunch of professional politicians who in their previuos lives were ambulance chasers (aka trial lawyers)

    December 24, 2009 at 10:22 | Report abuse | Reply
  37. Jason

    Comparative effectiveness makes statistical sense, however statistics cannot be applied to an individual. An insurance company may say that carpal tunnel syndrome can be effectively treated without surgery 85% of the time, and therefore will not cover an operation. This will offer little solace to someone who is in the remaining 15%. Insurance companies already look at comparative effectiveness for operations such as breast reduction, and physicians are required to obtain preauthorization for surgery, painstakingly documenting the nonsurgical treatments they have tried to alleviate these patients' neck, back, and shoulder pain before authorization for surgery is given. As soon as we have to start going through the same ordeal for every procedure we perform, I think you'll start finding a lot of our more talented surgeons leaving the profession, or at the very least no longer taking insurance.

    December 24, 2009 at 10:28 | Report abuse | Reply
  38. Dan

    One of the most important aspects of cost containment in my opinion would be to expose and prosecute those who commit medical fraud. There is always a lot written about such claims but little is done to actually expose the individuals and/or medical doctors that use fraud in billing practices.

    December 24, 2009 at 10:28 | Report abuse | Reply
  39. Paul A

    It's not about comparative effectiveness at all.

    20% of the people spend 80% of the money. It's the chronic conditions that are killing the health care system, and non compliant patients who refuse to stop smoking, refuse to lose weight, refuse to watch their diet to keep diabetes in control.

    The people who willfully cause more money to be spent should be the ones paying more money.

    December 24, 2009 at 10:31 | Report abuse | Reply
  40. Jim

    It's a great idea in theory to leave all options on the table for care. The problem is if this causes costs to skyrocket, then eventually the quality of care will suffer because the system will go bankrupt. The perception is that quality of care will suffer if don't perform every test and procedure available. The question I ask, do we really know? I don't think the insurance companies should be making this decision. But if it really does decrease costs without making quality of care suffer, why not do it if you can find a way to make the decisions accurately?

    The other thing I think about is that comparitive effectiveness is only one way of many to reduce costs. Some other is to increase efficiency at hospitals and clinics by following the example at the Cleveland and Mayo clinics with protocols and procedures to follow for doctors and other efficiencies. Another way is to create some sort of standard way for insurance companies to reimburse clinicis so doctors and hospitals don't have to have an army of administrative staff to wrangle with the insurance companies. Also automating the administrative process through updated IT systems can help. Having more generic drugs would help as well. There are some other ways to reduce costs that I have not touhced on here, such as tort reform and paying doctors and clinics by salary rather than by procedure might help.

    December 24, 2009 at 10:40 | Report abuse | Reply
  41. Tom Joas

    Comparative effectiveness is just another way of saying "pay for performance" which is a commonly used term in both the insurance industry and among knowledgeable medical practitioners. This goal is laudable and centers of excellence should be rewarded so that better outcomes receive better reimbursement. On the other hand we have already seen denial of claims when a second or third procedure has to be performed because of some problem with the first procedure. Finally, for example, comparison of outcomes of say tonsillectomy performed by a family practitioner versus the same procedure performed by an ENT physician would be like comparing apples to oranges.

    Changing the subject somewhat I would really like to know who is going to care for these newly insured ? Especially with a physician shortage and a nursing shortage. Will insurance coverage actually cover overhead and give the physician a small amount of take home pay ? Or will it be like Medicare/Medicaid where reimbursement rates do not even cover overhead. So there it is a continuation of a multi-tiered level of health care in the USA.

    Thomas A. Joas, MD

    December 24, 2009 at 10:58 | Report abuse | Reply
  42. Ross Price

    My appologies for going off on a bit of a tangent here but it seems to me some of these questions when asked tend to promote a lot of opposing opinions,,,,which is why there are blog sites but it also beggs the question,,,, how do we answer one component one side without looking at several sides to come to a beneficial "Path Forward". Ok so here is my input;

    Comparrative Effectiveness,,, interesting concept, I also saw a comment from Mitch on the 23rd that suggested pay for performance and I see other comments from folks concerned about doctors making recommendations based on training attained from years ago. They are all good and maybe it is not a one size fits all approach that is necessary but one that takes a much more multi-pronged analyitical approach to health care gauging what is effective or not but ultimately making it the call of the doctor who may at some point based on success and failure be compensated differently in the future if those ultimate decisions are in fact good ones on behalf of the patient. We've all seen what has happened to the economy and for many of the people who have survived in some areas of business it is because of the level of contribution and "up to date" knowledge of a given area. I make no negative judgement for any people who have lost their jobs, I have seen many personal friends and collegues go down in flames in this economy only by virtue of where they are sitting at the time the company decides to downsize, not by the quality of their work. Anyway back to the point,,,, Mich's concept,,,,, "Pay for Performance" based on the quality of of decisions that should be left to the patient and doctor, Qualititive, Quantitative, and Comparrative Effective analysis done quickly enabled by "high speed" data crunching performed by the insurance companies and the AMA (for example, not government) and not scads of people with subjective perceptions are all a good idea but it needs to happen quickly and be available on line.

    Finally the decision for care and the measures necessary for that care should never be left to the insurance company, they are not "hands on" with the patient nor do they have any history with that patient but the analysis of the quality of the decisions and the outcome for the patients should also be measured and be held accountable for their effectiveness. If the two sets of timely analysis are in fact pointing in a positive direction or at the very least maintaining a constant with only minor deviations we have definitely improved our systems. However, if the results prove to be less than desired by our highly trained but not necessarily current medical professionals and support staffs actions to compensate at a particular banding level until that analysis issued on an annual basis is improved by each registered participant.

    Quality of data improves
    Quality of decisions improves
    Quality of medical professionals and staff improves
    Quality of patient care and patients health improves

    All supported by data monitored by the Insurance Companies AND the AMA but ultimately the decisions are made between the Doctor and Patient, not an insurance company and not the government.

    December 24, 2009 at 11:07 | Report abuse | Reply
  43. TMW

    We are slowly becoming a 3rd world cxountry and this will take us to the brink. Why couldnt we simply expand the Medicaid program and build more clinic like settings in rural communities? Liberalizing the Medicaid program would cover the so called 30 million uninsured Americans and put people back to work at the same time.

    This is a terrible, terrible mistake.

    December 24, 2009 at 11:15 | Report abuse | Reply
  44. Doug

    The problem seems to lie in who determines what is effective and how effectiveness is determined. Unfortunately the politically connected and well funded organizations will continue to win out over new treatments that are supported by smaller and poorly funded organizations. The profit motive in healthcare is both a gift and a curse. It encourages innovation while crushing new discoveries,if these discoveries are unfortunate to be found by someone other than a big pharmaceutical company or medical device maker.

    December 24, 2009 at 11:33 | Report abuse | Reply
  45. earl in pa

    both my wife and i are disabled i collect social security and medicare . but my wife doesnt due to my earning for 2 people . she has no insurance due to we cant afford it . she;s been on the cobra list for almost 5 years now . will this new health plan help her and she is very sickly . i earn just a little over what the state requires so she cant get state help. ages are 51- wife 48 no other income

    thanks earl

    December 24, 2009 at 11:36 | Report abuse | Reply
  46. Michael

    Consider the NFL employer based health care system not working very well. The historically employer provides excellent health care during the life of the athlete’s career but significantly drops off after the athlete’s service. I believe this is typical of all employer based systems; they are only interested in maintaining the employee’s health during their employment which is almost always short term. This is short term thinking when it comes to individual long term health.
    Comparative effectiveness? Consider Bert Farve, he had off season surgery on his throwing arm that the average individual may not have had but was certainly important to his career and obviously effective. I for one would not want to “ration” an individual opportunity or need but on the other hand I don’t want to share the burden of that health care service with our health care system. So somehow this needs to equalized. Perhaps taxing the “Cadillac” side of health care services may be the answer. After all in the money that pays people like Bert Farve actually comes from “The People”.
    Food for thought.

    December 24, 2009 at 11:56 | Report abuse | Reply
  47. Jack Chilton

    Not only do I believe in comparative effectiveness, I am of the opinion that a review of this type whould have been a logical second step, right After Tort reform. Has anything ever been less expensive when attorneys are involved? Get the attorneys in line, protect medical professionals from excessive insurance costs, use comparative effectiveness to whittle away the excesses, make sure the resulting savings from all of the above make their way down to the pockets of the public and their employers. Creating a healthcare system that doesn't force medical professionals to be such mercenaries would drive much of the waste away.

    December 24, 2009 at 12:01 | Report abuse | Reply
  48. Keith Bruhnsen

    The $80 billion dollar additional coverage for Medicare Part-D participants to cover the "donut hole" is limited to purchases of branded expensive drugs. You need to see through the smoke of the pharmaceutical companties that intent to get physicians to switch patients from lower cost generic drugs to expensive brands that add no additional value and the patient then has a 50% copay. Branded drugs average over $200 a month compared to generic at $20-30 month.. This is health care reform?

    December 24, 2009 at 12:43 | Report abuse | Reply
  49. Boomer in Mo

    Americans want a pill or an operation for everything. They also want to live forever, and have no idea what they are asking for. Spend as much time in a nursing home as I have since April and you will see what a curse living for a long time is for many, many people. I walk for my bad knees and hope to never need an operation. I had back surgery due to an injury 11 years ago and to this day do the exercises the physical therapist taught me. I take allergy medicine most days, and wish I did not have to. I've found the majority of physicians over treat, over prescribe and generally are looking out for their wallet, not my health. They can't make money if they tell someone to exercise. Better to fill them full of potions and have them come in for a check up once a month.

    December 24, 2009 at 13:15 | Report abuse | Reply
  50. John

    The methods of comparative effectiveness research have not received as much scrutiny as the traditional methods of randomized clinical trials and cost-effectiveness analysis to calculate quality years of life saved. Some of the CER methods incorporate newer ways of assessing cost-effectiveness. Because most doctors have not studied much in the science of decision analysis, they are mistaken to think that all of the conclusions of comparative effectiveness research are based on scientific evidence. Some of the methods bypass traditional tests for scientific validity. Therefore your practice may be restricted by someone making a value judgment who doesn't even practice medicine. This is a new version of the clerk in the insurance company or the bureaucrat in the VA denying payment for a procedure you are recommending for the patient.

    While comparative effectiveness research may be the only practical method of assessing most of the possible medical interventions, it can really be abused by those with an agenda. I think that it would be better for comparative effectiveness research to give medical providers targets for effectiveness of treatments, rather than decide that treatments are not effective.

    For example, we all know some doctors have better results for surgery for back pain. We also know that large scale studies (not randomized clinical trials) produce statistics not favorable to surgery for back pain. Rather than lumping all surgeons and procedures together, and deciding that back surgery is not effective, they should state that the surgeon should achieve at least 30% more patients returning to work for a total of one year, with fewer than 5% complaining of more pain after surgery (a hypothetical example comparing back surgery to conservative therapy). That assessment can then be openly debated in political forums. Then surgeons that maintain the accepted standards can offer the surgery to the patient, and the patient have the final decision about the harms, benefits, and cost.

    December 24, 2009 at 13:34 | Report abuse | Reply
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