Health reform forecasts and the Great Society

Even the most die-hard NCAA basketball fans should concede that the major headline of the past weekend was not Northern Iowa upsetting Kansas or Cornell advancing to the Sweet 16, but the health reform reconciliation bill squeaking through the House of Representatives by a 7-vote margin. So should we be celebrating along with President Obama's crowd or throwing in our lot with the Tea Party? I'll dodge that question for now, but suggest that history provides a possible answer, or at least an analogy. In her acclaimed biography of President Lyndon Johnson, historian Doris Kearns (now Goodwin) wrote this about Johnson's relentless political pursuit of the mid-1960s social welfare agenda that would collectively come to be known as the "Great Society":

Even in the more familiar areas of public policy, the need for haste often resulted in a failure to define the precise nature and requirements of social objectives. Legislative solutions were often devised and rushed into law before the problems were understood. Since time was limited and agreement on ends could be assumed, since surely all reasonable men - especially those likely to be consulted by a liberal Democratic President - favored the elimination of poverty, the expansion of educational opportunity, and improvement in the delivery of medical care, most of the attention was focused on means. ... as if putting more money into a poorly conceived system will inevitably make it better. Pass the bill now, worry about its effects and implementation later - this was the White House strategy.

Sound familiar? A common critique that has been leveled at the health reform bill from both extremes of the political spectrum (those who want a Canadian-style single-payer health system and those who are basically fine with the status quo) is that it isn't real reform at all, but sinking billions of additional dollars we don't have into the current system. Of course, some will be quick to point out that one of Johnson's "hastily" enacted Great Society programs was Medicare, the health insurance program for senior citizens that is not by any means flawless, but has become so successful and widely accepted that opponents of "government-run health care" were forced into the paradoxical position of attacking the bill because it might threaten the generous benefits currently provided by Medicare.

Like picking who will emerge from this year's March Madness at the beginning of the season, it's much too early to correctly forecast whether this health reform bill - which may not survive the next round of Congressional elections - will turn out to be (like Medicare) a rousing success, an incremental improvement, or a catastrophic failure. Liberal commentators such as the Washington Post's Ezra Klein are already calling for additional reforms, while 11 states, fearing the possible effect of unfunded mandates on their battered budgets, plan to sue the federal government to prevent implementation of the bill. In the meantime, my thoughts on this topic are perhaps best summed up by the question I asked my wife (also a family physician) as we were listening to the final hours of floor debate while driving home on Sunday evening:

"So what are those 32 million newly covered people going to do when they get their health insurance cards and can't find a family doctor to see them?"

How fragmented U.S. health care endangers expectant moms

As I noted previously, the steady rise in the percentage of babies delivered via Cesarean section (currently just under 1 in 3 deliveries in the U.S.) is due in large part to "too much care" - a high-technology mindset that permeates training programs in obstetrics and gynecology, combined with a low tolerance for uncertainty driven by concerns about malpractice lawsuits. While surgical deliveries are sometimes unavoidable, it's clear that less interventional maternity care providers such as midwives and family physicians can spare many more women from having C-sections, with comparable maternal and infant health outcomes.

However, for many expectant mothers, the problem is too little care - poor access to prenatal care to poverty, a lack of health insurance, non-citizen status, or other barriers. "Deadly Delivery," a report released earlier this month by Amnesty International, chronicles the failure of the high spending U.S. health system to provide adequate prenatal care for 1 in 4 women, leading to a maternal mortality rate that ranks 41st in the world and has more than doubled over the past two decades. The report observes that 13 million women between the ages of 15 and 44 are uninsured, and many who become pregnant have trouble obtaining Medicaid coverage due to bureaucratic obstacles. Even women who obtain coverage have a hard time accessing care due to a shortage of maternity providers in rural and urban areas.

Living and working in the Washington, DC area since 2004, I've seen firsthand how difficult it is for uninsured women to get good prenatal care, despite a physician to population ratio that is one of the highest in the nation. It isn't surprising, then, that pregnant women in the District of Columbia have a risk of death that is nearly 3 times the national average, and more than 7 times the Healthy People 2010 goal of 4.3 deaths per 100,000 live births. The only five states that have achieved that goal are Massachusetts, Vermont, Minnesota, Maine, and Indiana. Interestingly enough, Massachusetts, Vermont, and Minnesota are #1, 2, and 3 in state rankings of the lowest percentage of the population without insurance. Coincidence? I think not.

Eminence-based medicine and prostate cancer treatments

Until the arrival of evidence-based medicine (EBM) movement in the 1980s, medical training and continuing medical education in the U.S. were guided by what might be called the other EBM, "eminence-based medicine" - that is, physicians made decisions about patients based largely on what their attending physicians taught them to do in medical school, what therapies respected colleagues told them to do, and what review articles written by those gray-haired eminences instructed them to do, regardless of what actually worked. By the time I entered training in the late 1990s, a few things had changed for the better, and useless or harmful therapies such as estrogen for menopause, high-dose chemotherapy with bone marrow transplanation for breast cancer, and drugs to suppress cardiac arrhythmias were exposed for what they were in randomized clinical trials.

But sadly, much of medicine continues to operate in an evidence-based vacuum, and nowhere is this state of affairs more painfully evident than with treatments for clinically localized prostate cancer (prostate cancer that is detected via a blood test and confirmed by microscopic examination of a biopsy sample, but causes no symptoms in the patient). Not only is there little reliable data to support choosing one type of therapy over another, for many men the option of deferring therapy (called "watchful waiting" or "expectant management") may be superior to all of them.

So how do men decide what therapy to choose for this condition? They consult physicians, which would be a sensible thing to do if different types of physicians actually agreed what therapy to recommend in specific situations. Unfortunately, a recent study published in the Archives of Internal Medicine confirms what I had already suspected from my own experience: eminence-based medicine is alive and well. Rather than rationally selecting therapies based on their personal health status, tolerance of uncertainty, and preferences for certain side effects over others, patients with prostate cancer overwhelmingly choose therapies based on the type of physician they happen to see. Men who visit a urologist between the time of cancer diagnosis and treatment are most likely to choose surgery, men who visit a radiation oncologist are most likely to choose prostate irradiation. Meanwhile, men who also visited their primary care physician were most likely to defer therapy regardless of what specialist they saw, but only 1 in 5 men in the study actually had a primary care consultation.

While the health care bill pending in the House of Representatives will not solve this problem, it does contain some essential elements: support for primary care, research on the effectiveness of common therapies, and support for unbiased organizations that evaluate this research to decide what is or is not a worthwhile use of limited health care resources. These are the necessary first steps to ending the era of eminence-based medicine.