Friday, November 20, 2009

Decoding the Surrealistic Landscape of Health Reform

By this time anyone reads this the arguments in Congress may be over.

Joseph Lieberman et al may have even prevented a vote. My prediction: Leiberman's next incarnation will be as Shining Path Maoist. Based on principle, you know.

Regardless, this whole "health care reform" plan is a travesty. It's a giveaway to private insurance companies, a sop for big pharma, and makes care more complicated for the average person to obtain.

Anyone who thinks about this issue, and does not work or lobby for, the insurance industry, can see that using private insurance and linking it to employment is a recipe for wasteful and inefficient spending.

The solution has been staring us in the face for decades, but particularly in the last few months.


What we need is a single payer system.

This does not mean the end of private practice. In fact, it very closely resembles Medicare, which is, pardon the expression, a single payer system that is known to work.

The Veterans Affairs medical programs (some of which are a substandard disgrace) are also single payer, and if Republicans stopped obstructing and obfuscating everything that crosses their desks, Congress would allow an increase in spending for the VA health care system.

Somehow, I am chosen to participate in telephonic town hall meetings. Always happens at dinner time. The phone rings, I answer with typical trepidation, and am informed that I have been selected for this cyber town hall thing.

The first one was for U.S. Rep. Rosa DeLauro, who took many calls, a high percentage tearful, from people begging to know how health reform will help them. Small business owners were also wary.

When my turn finally came to talk, I asked, since most of the previous callers were complaining about medical insurers, why was the single payer option eliminated without serious consideration? Why are we catering to the insurance industry, I asked, and was then placed on "listen only."

I cannot recall was Rep. DeLauro said, but a male aid of hers told me that a single payer system would make workers who receive benefits through their jobs unduly "anxious" about the system.

Right. Workers have no anxieties in Connecticut, do they?

The answer was silly. When 64-year-old Americans become 65, they are eligible for Medicare, and he sky does not fall. The heavens do not darken. The federal government does not grind to a halt.

The 65-year-old receives a Medicare card, and gives the information to his doctor. His doctor probably takes Medicare cases. If not, he finds a doctor who does.

Covering everyone in the country with an expanded Medicare plan would cut billions of dollars in waste by insurance companies whose sole motive is to collect money, and keep money by refusing claims.

Given a choice between arguing with a disinterested government official and an unidentified professional confounder at an insurance company, I know what I would rather choose.

Instead of the simple Medicare for all plan, if health reform pans out, we will be able to keep the plans we're on, or shop for insurance from an exchange, including an anemic public option.

If you remember the complexity of Medicare Part D, the prescription plan with the famous doughnut hole, the coming plethora of plans will seem familiar. Figuring out the best, or least bad, Part D plan was the equivalent of breaking the German enigma enciphering machine.

The insurance companies would not release their formularies, and could change them without notice. There was a substantial penalty for not signing up quickly.

Well, you can imagine what "shopping on the exchange" will be like. You'll get a list of covered items, premiums and deductibles, along with a list of exceptions. Everything will require pre-authorization, I suspect.

One plan I recently saw for mental health requires prior authorization, and does not cover marriage counseling, pervasive developmental disorder, or a bunch of other conditions. You call the company for authorization and talk to someone, clearly not a doctor, with a Mumbai accent, I'm imagining.

If health care is a right, as some people claim, the system we are likely to end up with is a mockery.

Which also points out that regardless of what our elected officials say, our domestic and foreign policy is determined by ExxonMobil, Well Point, Humana, SmithKlineGlaxo, General Dynamics, Boeing Lockheed, and Wall Street.

Each woman is an individual and her breast care is her business

The federal Preventive Service recommendations on mammograms is not about rationing health care, although it does involve economic considerations.

Repeat, the "fewer mammograms" suggestion is not about parsing care, it relates to breast cancer as a public health issue, not a personal one.

Here it is in a nutshell: Do the anxiety, biopsies, surgeries, and expenses of mammograms justify their current use by women, not at any special risk, starting at age 40.

Studies show that one case of breast cancer is discovered by mammogram per 1,904 women tested. The problem is that the other 1,903 women may receive false positive results, meaning that they then undergo a biopsy, and possible surgery.

complications in biopsy and surgery are rare, but not unknown. Depending on the skill of the doctor "reading" the mammogram, the x-ray may show benign lesions, cysts, or "artifacts" such as shadows that aren't really there.

Suppose there were an extremely rare fatal disease curable if caught before the age of 5. Say this disease struck 1 person in 1 million. Even if the test were cheap, easy and accurate, a million people would need to take and pay for the test to reveal that single case, on average.

Clearly, for the diseased individuals, these kinds of screening tests can be lifesaving. But what if your doctor recommended the test, even though the chances of it occurring in your child were minuscule?

You might ask your pediatrician if it made sense to test everyone, because the risk is only 1 in 1 million, getting time off from work is a hassle, a doctor bill is a hassle, and putting a toddler through a medical test is emotionally and physically draining.

On the other hand, diseases like measles, mumps and rubella were so common and the vaccines so inexpensive and effective that virtually all children in the U.S. receive them before they are allowed to attend school.

Currently, about 1 in 8 women will develop breast cancer in her lifetime. Breast cancer is not a single disease; there are aggressive, invasive types, and slow growing types. Women with certain genetic mutations are more likely to develop breast cancer.

So undergoing mammograms at age 40 seems reasonable.

The five-year survival rate for breast cancer in women in the U.S. is about 89 percent, which is encouraging.

Here's what puzzles and confounds many men and women. Canadians followed 40,000 women ages 50 to 59 in the 13-year study that concluded in 2000. The women were split into one group who received physical exams and another that were given mammograms.

The Canadians found that though more cancers were detected by mammograms, their death rates were no lower than the physical exam group. The inescapable conclusion is that yearly mammograms did not increase survival rates after cancers were detected.

Can this be true? It makes little sense. The methodology of the test was criticized, including the quality of the mammograms. The age of the participants is another issue. All of the women probably faced an elevated risk, skewing the results.

This is why it is so important to read and understand medical reports and journal articles. Why it is important to study biology and physiology. You don't need to agree with evolution to be a good doctor, though genetics is part of an educated person's knowledge.

Even if the study had been conducted perfectly, epidemiology has to do with large numbers of people. Medicine pertains to the individual.

So when all is said and done, here's what you should do: Consult your own doctor or doctors about whether they think you should get or delay mammograms. Because you're the person at risk for breast cancer.

This is your life, and you should not allow an obscure public health meta-study to dictate what medical tests you choose, and when you choose them.