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. Pat

    My fervent hope is that the people who backed this bill with so much intensity that they couldn't see consequences, will be the ones subjected to the 'rationing" of much needed tests or surgery.

    December 24, 2009 at 17:14 | Report abuse | Reply
  2. John

    Danni N is absolutely correct. There are so many different numbers you get from the methods of comparative effectiveness evaluation. You can emphasize the numbers that support your agenda. For example in the USPSTF recommendations, they report that 1904 women aged 40 to 50 have to be screened to save one life from breast cancer. You could also report that if all women in the age group 40 to 50 in the United States were to have annual mammograms for 10 years, we could save 11,554 women from dying from breast cancer (22 million divided by 1904).

    The practice of medicine is considered an art, and not a science, because you consider all of the individual factors and values of an individual patient, as well as the scientific evidence, when you make a recommendation to the patient. A good clinician has almost always been able to do better than any decision analysis using mathematical methods of probability and data assessment.

    Comparative effectiveness analysis will significantly cut down the number of imaging procedures for headaches and back pain, as well as surgeries for back pain, arthroscopies for knee or shoulder pain, endoscopies for abdominal pain, angioplasties for chest pain, handing out antibiotics for sore throats and colds, etc. But some of those patients might have actually benefited from those interventions. It would be better to figure out which providers are motivated to do those interventions for profit (or covering their ass from malpractice), and which are giving their best recommendation to the patient. At least two amendments to the healthcare reform bill would have targeted unnecessary procedures for reductions, but were defeated. Instead of standing up to the lobbyists, the legislators decide we must have more governmental control so they can spin the numbers to their desire. Then the government can decide what to recommend to the patient, not the doctor talking to and evaluating the patient ( practicing the art of medicine).

    We wouldn't need healthcare rationing in any disguise, if we could effectively reduce unnecessary tests and procedures. Comparative effectiveness research will reduce more unnecessary procedures than deny necessary procedures. But why do those patients who could have benefited have to suffer, just because the legislatures are under the control of lobbyists?

    A good use for comparative effectiveness research would be to come up with certain guidelines, which if followed, would protect you from a malpractice lawsuit.

    December 24, 2009 at 19:53 | Report abuse | Reply
  3. doctor_overbyte

    The so-called "Cadillac" plans tax is a deceptive provision of the Senate bill. It imposes a 40% tax on plans that cost more than $8500/year for an individual. I just got an online quote from the largest health insurance company, for a 45 year-old with $500 deductible and 70% insurance copay in my area. It would cost more than $8500 per year. That's not a luxury "Cadillac" plan. It's not even a great plan. This provision sets the "Cadillac" limit too low and will increase costs for a large portion of insured people. It's a sneaky provision to tax a lot of insurance plans so there's money to subsidize the low-income people, without showing the cost in the budget deficit figures. It's dishonest. It's like saying we're only taxing the rich, and defining rich as anyone making more than average income. Dr. Gupta, I haven't heard you comment on this in your TV shows.

    December 25, 2009 at 10:56 | Report abuse | Reply
  4. April

    Dr. Gupta,

    I definitely favor comparative effectiveness. I also have no problem with rationing (even though I know there is no such thing).

    December 25, 2009 at 11:42 | Report abuse | Reply
  5. Michael Dick MD, Decatur, AL

    You stated that one way of paying for health care reform is to cut reimbursement to providers. Your readers should know that it would result in fewer primary care physicians accepting Medicare patients.

    December 25, 2009 at 12:51 | Report abuse | Reply
  6. doctor_overbyte

    Last year our local newspaper ran a long article about the trouble seniors are having finding doctors who accept Medicare in our area because the Medicare fee payments are too low. Cutting fees further will drive out more doctors unless they have no alternative to make a living. Since single-payer is out of the question at this time, there's always a way out for the doctors who have non-Medicare patients. What doctor would go into geriatric care with this kind of cut-cut-cut sword hanging over his or her head?

    December 25, 2009 at 19:45 | Report abuse | Reply
  7. j. Watkins

    I hope mental health will finally be taken as seriously as physical.

    December 26, 2009 at 22:56 | Report abuse | Reply
  8. Sarah Roberts

    Who am I? I have written on the Dr Timothy Kuklo, Washington University in St Louis School of Medicine case extensively which dealt with the Medtronic disgrace with falsified research, misleading data, fake co-authorships and the like. I wrote more on this case than any other online source and have gotten 10,000s of hits. But, who am I? I am a patient at Northwestern Bluhm Cardiovascular Institute and I have noticed that patients’ views are considered inconsequential by both the press and Northwestern unless they are litigants. Interesting if not elitist. Well I have strong views on this scandal and a stake in its outcome.

    Check out this blog and see if you can make healthcare in Chicago safe for us Chicagoaons. Thanks Sanjay!


    December 26, 2009 at 23:43 | Report abuse | Reply
  9. Donna

    Comparative effectiveness leaks significance along the precarious journey of inventing standards in health care. Patient conditions cannot always be standardized. Human situations and illness are unique and the physician's diagnosis and plan of treatment can be brilliant, woefully uninspired or hazardous to health. Insurance companies are vested in saving money and denying procedures in their effort to save the bottom line (and to enhance CEO/Board of Director's remuneration). It is hazardous to the health of this nation to entrust healthcare to Wall Street's oxymoronic ethics.

    When Western medicine joins hands with naturopathy, acupuncture, homeopathy with the praxis of affordable healthcare for all, then, this society will be an international beacon once again. This is what an egalitarian and healthy democracy looks like.

    December 28, 2009 at 00:25 | Report abuse | Reply
  10. Debbie

    Could comparative effectiveness in the healthcare industry be compared to what those in the substance abuse industry refer to as choice by the addict to seek substance abuse treatment? We know intervention and treatment aids in recovery and abstinence and is optimally effective when the addict is an active participant in planning their own recovery and aftercare program. If comparative effectiveness is solely depended upon to treat healthcare issues, then we as a country may end up needing 'sick camps' or larger hospital systems that could be compared to the pretrial diversion programs substance abusers become a participant in when the county is trying to 'divert' from its prisons rather than fill them. We may end up creating a larger problem for ourselves in the long run if we depend upon comparative effectiveness to dictate continuum of care.

    December 29, 2009 at 10:51 | Report abuse | Reply
  11. Franky, Land of Lincoln

    Consider the following example:

    "Imagine the United States is preparing for the outbreak of an unusual Asian disease(or H1NI), which is expected to kill 600 people. Two alternatives programs to combat the disease have been proposed. Assume that the exact sicnetific estimate of the consequences of the program is as follows: If program A is adopted, 200 people will be saved. If program B is adopted, there is a one-third probability that 600 people will be saved, and a two-thirds probability that no people would be saved. Which program would you prefer or favor?

    Now imagine the same situation with these two alternatives: If program C is adopted, 400 people will die. If program D is adopted, there is a one-third probability that no one will die, and two-thirds probability that 600 people will die."

    Sources:(Based on Tversky and Kahneman, 1982).

    When the problem was framed in terms of lives saved, 72% of the participants chose program A. However, when the program was phrased in terms of lives lost, 78% favored program D, and only 22% favored C, which has the same outcome as program A!

    Such findings may affect how health warnings, labels, or other risks(like health inspections, news, etc), should be presented and may illuminate systematic BIASES in the everyday decisions people make.

    PS: All I want for our leaders to do and the NEWS, is to be careful what you say, what you do and what you believe, I'm more smarter than before, 🙂

    December 30, 2009 at 11:27 | Report abuse | Reply
  12. Henry Bensimon

    I am a senior, 70 years old. I've had a Medicare Advantage Plan with SCAN. This year the SCAN plan has raised the price for the Tier 3 medications for a 3-month supply (mail) from $56 to $80. That's over a 42% increase compared with last year (2009). Others were raised about 25%.

    I am not sure what the reason is for this huge increase but I wonder if it has anything to do with the soon to be approved Health Care Reform. It's probably a preventive reaction that can be compared with the changes the credit card companies made just before the legislation regulating them went into effect.

    The ironic fact is that the SS retirees did not get any increase for 2010 but all the taxes and fees are going up at an increasing speed, especially here in California. I don't know how I am going to make ends meet on my SS pension.

    January 5, 2010 at 03:53 | Report abuse | Reply
  13. Francesco Cece

    It is unconstitutional to force feed Americans to pay for a bill they choose not to take part of. There is nothing written in our constitution that states the this government has the right to use tax payers money to mandate health care for people who by choice willing to have a government given free health plan. As an American, I choose my own!
    Government can be sued for this!
    Since the 1930s, the Supreme Court has been reluctant to invalidate “regulatory” taxes. However, a tax that is so clearly a penalty for failing to comply with requirements otherwise beyond Congress’s constitutional power will present the question whether there are any limits on Congress’s power to regulate individual Americans. The Supreme Court has never accepted such a proposition, and it is unlikely to accept it now, even in an area as important as health care.
    Congress could evade all constitutional limits by “taxing” anyone who doesn’t follow an order of any kind—whether to obtain health-care insurance, or to join a health club, or exercise regularly, or even eat your vegetables.

    January 7, 2010 at 09:33 | Report abuse | Reply
  14. Public Option Supporter

    I agree that there seem to be constitutional questions, but nothing in the constitution expressly requires government to provide for emergency healthcare to people without regard for ability to pay or even legal status in the country, but we are taxed to pay for such public services whether we agree or not. We have mandatory seat belt and motorcycle helmet laws which fine us for not complying. I don't see that a fine for not enrolling in a health plan is constitutionally different from those regulations. Congress is authorized to provide for the public welfare, and mandatory health insurance purchase seems to be just one more way to do that. The bigger problem is that the fines are just a pat on the hand, not anything that really gives incentives to comply. Without significant penalties, people will decline to get insurance, pay the token penalty, and then enroll (without regard to existing conditions, remember) only when they get sick and need the medical insurance. That's called "adverse selection" and it will cause all of us to pay much higher premiums and may even bring down the whole scheme if it catches on.

    January 7, 2010 at 14:14 | Report abuse | Reply
  15. Patrick Pearson

    Dr. Gupta,

    I saw your show Sat. Jan. 9th and your interview with Dean Kamen.

    I am always threatening to write when something either bothers me or impresses me that I see on TV or read in the paper and never do, but this time I just had to write.

    I think Dean Kamen hit the nail on the head talking about 'health care reform' saying our real future is in research not a few dollars cheaper in health care policy costs. I also believe that what is going on in Washington isn't health care reform it's just partisan politics and posturing to see which senator or congress person can get the most for his or her district.

    There may be senators or congressmen with a higher IQ and considered smarter than Dean Kamen but I think he has more common sense than the whole congress collectively.

    Pat Pearson

    January 9, 2010 at 09:18 | Report abuse | Reply
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Get a behind-the-scenes look at the latest stories from CNN Chief Medical Correspondent, Dr. Sanjay Gupta, Senior Medical Correspondent Elizabeth Cohen and the CNN Medical Unit producers. They'll share news and views on health and medical trends - info that will help you take better care of yourself and the people you love.