One of the fastest ways to cut health care costs is to make intelligent choices. That’s not as easy as it sounds. While politicians and insurance companies talk about having decisions made by physicians, not bureaucrats, you might find yourself better served by a disinterested bureaucrat than an insurance company or even your trusted physician. While the Republicans are railing against having the government make decisions, for most of us, treatment decisions are being made by insurance companies, and they’re more concerned with their profit margins than they are about you. The insurance company decides what’s covered and what’s not, what drugs you can take, what physicians you can see. In some plans these are absolute prohibitions, in others there’s a co-pay that puts some tests or treatments out of reach. The insurance company makes money by saying no.
Unlike your insurer, your physician really does have your welfare in mind, but that’s no guarantee of the best treatment either. The pharmaceutical industry and medical device manufacturers devote tremendous resources to influencing the way physicians think. Even though the pharmas and device manufacturers have sworn off expense account lunches, educational seminars at golf and ski resorts, “research” grants and even ballpoint pens and sticky pads, they keep up a steady drum beat of advertising and sales calls. A good salesman doesn’t have to offer pens, pads and pizza to influence behavior, and the medical suppliers can afford to hire the best sales staffs anywhere.
Meanwhile, the patient is stuck in the middle. While physicians are supposed to discuss treatment options, risks and benefits with the patient, this is done in a cursory manner if it’s done at all. This can be a real problem when the physician has been cajoled into ordering the newest, most expensive treatment, and the insurer, whether the infamous government bureaucrat or, if you listen to the ads, benevolent insurance company clerk, refuses to pay. We trust our physicians, which is why the idea of decisions made by patients and doctors is invoked so often, even by those who actually make the decisions — even when the doctors’ waiting room is as crammed with ads as the hood of a NASCAR coupe.
President Obama is right in saying that we need health care research to weed out ineffective treatments. This could provide valuable information, both for physicians to learn what works, and so that patients can learn whether their physicians are making wise choices. We call for transparency in government and finance, and we should also demand more transparency in medical care. Right now, we have a large body of medical literature, but too much of it consists of studies carefully designed to give a predictable result, or studies written to give the desired result whether it was achieved or not. Sen. Charles Grassley (R-Iowa) has been quoted as saying, “I support making sure that patients and doctors have up-to-date and effective information, but I would doubt support for reforms that allow some government bureaucrat to interfere with a doctor’s ability to practice medicine.”
What President Obama is asking for is called “evidence-based medicine,” the idea of getting the facts as best you can, and making decisions based on them. The alternative, advertising-based medicine, is what we have now, and it’s hard to see how it’s better.
There are efforts at objective evaluations, and some of them are very good. Canada has its Therapeutics Initiative, available to anyone with an Internet account, in English, French and Spanish. Other sources have price tags. Information wants to be free, but providers have to have their expenses covered. The Medical Letter, published by a non-profit foundation, costs $98/year for an individual subscription.
One of the best resources is the Cochrane Library, a non-profit international volunteer collaboration which publishes objective, detailed evaluations of medical treatments so that both providers and patients can make informed decisions about treatments. It’s a wonderful resource — so wonderful that whole nations subscribe, and anyone in those nations can get the information. India has a national subscription, and so do Norway, Denmark, Spain, Poland and Sweden. Everybody in Latin America and the Caribbean can access the resources. The Cochrane Collaboration provides free access so people in low-income nations have access to objective information about medical care, but in the United States, only Wyoming offers all citizens access to this material through the Wyoming Libraries Database.
The Republican Party warns against evidence-based medicine the way an appliance salesman warns against trusting Consumer Reports — but the President is right, and the GOP is wrong. Access to objective information and transparency in healthcare decisions will improve quality and reduce costs, and while a federally funded center with lots of resources would help a lot, we have a starting point already available — if you happen to live in Wyoming.
Sam Uretsky is a writer and pharmacist living on Long Island, N.Y.
From The Progressive Populist, September 1, 2009
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