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(HealthNewsDigest.com) – A “time-out” for bad behavior, removes a toddler from the situation where he is acting out, and sits him in a chair or in another room, telling him that he is in “time-out” from the activity. This is what is desperately needed for Obamacare.
What, after all is the urgency? Why did we, as a nation, fail to engage in serious discourse on social security’s insolvency, a legitimate crisis that looms large for every American, yet can’t wait to put 1/6 of the economy in the hands of a new bureaucracy at a cost of $1.5 trillion. This to meet the needs of 47 million putatively uninsured or 15.7% of the US population? The answer is that there is no crisis in healthcare. There is no emergency. Instead there is an administration driven by the principle articulated by Rahm Emanuel its anointed architect that, “You never let a serious crisis go to waste.” And it follows, that if the is no crisis, you simply invent one. Like Tito’s Yugoslavia, that nationalized healthcare as one of its first official acts, the current governmental troika of house, senate and executive braches have their sights on a lynchpin of American society.
Whipped into a frenzy of Chicken Little proportions, politicians are now groping for quick fixes. They want metrics to gauge risks, costs and returns on investment. Comparative Effectiveness and Evidenced Based Medicine are the calipers dujour. These blunt instruments are being forced upon medical care despite the obvious bad-fit. Deftly applied by policy wonks and systems analysts, these tools function perfectly within their stated performance characteristics. Yet they remain largely irrelevant to the very human subject at hand…a degree of irrelevance that is at once recognized and dismissed by a coterie of pseudo-scientists mesmerized by their new found medical number crunching capabilities. They are simply enjoying this too much to worry about the implications of destroying a discipline with origins as old as the human specie itself.
As a primer on things to come, one need only examine the recently published analysis of Institute of Medicine’s 193 priorities for Comparative Effectiveness Research (John K. Ingelhart, New Engl Jour Med, 361:4 July 23 2009). Bar graphs plot the number of projects against specific areas of investigation. At the top of the list is “Heath Care Delivery Systems” with 50 followed by “Racial and Ethnic Disparities” at 29 and “Functional Limitations and Disabilities” at 22, constituting in aggregate 101/193 (52%) of the total. By comparison “Cardiovascular and Peripheral Vascular” at 21 and “Oncology and Hematology” at 11, together, the leading causes of death in the America, come in a paltry 32 (17%). In this Dilbertian future, we will be spending more and more of our limited medical resources on the study of the study of medicine. However appealing to government-funded academics, this is little more than a make-work program for ivory-tower investigators, whose contact with human patients grow more limited by the day. Practicing physicians will be abdicating control over their well-honed skills to those will little ability and a diminishing interest in the practice of their chosen art.
Evidence Based Medicine is the second rallying cry of policy makers and academics. It has its origins in the work of Archie Cochrane (1909-1988), an English physician whose experience in medical practice came largely during WWII as a prisoner of war. His guidelines, known as Levels of Evidence have become the backbone of many medical delivery systems including the UK’s National Health Service and its stalking horse, The National Institute for Health and Clinical Excellence (NICE). The obvious appeal of scientifically grounded medical decision-making, leaves something to be desired when one scrutinizes how it is being applied in practice. By Cochrane standards, all medical care should be delivered based upon what he described as Level I evidence. This is generated in randomized, (preferably) double blinded, controlled clinical trials wherein treatment “A” is compared with treatment “B”, and neither caregiver nor recipient know the treatment arm to which they have been assigned. Unassailable on theoretical grounds, Evidence Based Medicine falls flat when one realizes how few medical interventions can or ever will rise to this standard. Shall we withhold appendectomies from half the patients with severe abdominal pain and suggestive X rays to “prove” that the surgery is effective? Has anyone ever done such a trial? If not, should they? What about electrical cardio-version for ventricular arrhythmias? In fact, the majority of medical care cannot meet Cochrane standards, yet the new government bureaucracy and its cadres of academics will demand that medical advances prove their worth in the Cochrane court of evidence. An article in the British Medical Journal from 2003 (Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials. Smith GC, Pell JP, BMJ 2003 Dec 20;327) that promoted a randomized trial to prove that parachutes prevent injury and death put evidence based medicine and its dogmatic adherents clearly in focus. It is unfortunate that many physicians and the public at large are not more familiar this rigid governor of medical care delivery, actively being forced upon doctor’s practices. It has the potential to stifle medical advances and curtail access to effective care under the ruse of cost containment and “good science.”
Medical care in America is not broken. It delivers the best care in the world. Eighty percent of Americans are insured and everyone in America gets care. Rather than engaging in the big fix, we can and should simply repair those components that are damaged. The governmental dumming-down of care delivery that places decision in the hands of robotic automatons and regresses toward the mean of “average outcomes” will undermine everything that is good and humane about our system. The very notion that third party payers should “decide” how much care you need is anathema to the most basic tents of American existence. By extending this power to government workers we will surely achieve a medical system with the efficiency of the post office and the compassion of the customs service. Economic man strives to meet unlimited wants with limited resources. Economics teaches that consumers will price the value of a service delivered whether it be automobile tires or cardiac surgery. The intricacies of tire bias or of light fixture manufacture are every bit as opaque to the average consumer as is the quality of the chemotherapy delivered at a major institution, yet Consumers Reports and Underwriter’s Laboratory have come to existence to make these purchases safe and understandable. The Internet and a new industry of Medical guides who assist patients in complex decisions are already making this type of oversight a reality.
As we have been granted the month of August to examine and consider this mammoth healthcare legislation, Americans should very politely say to their elected officials: No thank you! It is time for the Obama administration and congress to take a time out. We suggest that they sit quietly and ponder the very real crises that confront the US today and leave the medical care system alone.
Editor’s note: Robert A. Nagourney, MD, is Medical and Laboratory Director at Rational Therapeutics, Inc., in Long Beach, California and Adjunct Associate Professor of Pharmacology at the University of California at Irvine. He is board certified in internal medicine, medical oncology, and hematology.
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