SEPTEMBER 1, 2009
By JANET ADAMY and JONATHAN WEISMAN
WASHINGTON -- Recent town-hall uproars weren't just about health care. They were also eruptions of concern that the government is taking on too much at once. That suggests trouble for the president and his party, and fears of losses in next year's midterm election are likely to shape the Democrats' fall agenda. The uproar at town-hall meetings in August has been as much about the role of government as it has been about the health overhaul, WSJ's Janet Adamy reports. At August's town-hall meetings, voters often started with complaints about health care, only to shift to frustrations about all the other things President Barack Obama and the Democrats have done or tried to do since January. The $787 billion economic-stimulus package, the government-led rescue of General Motors Corp. and climate-change legislation all came in for criticism. "A lot of the anxiety we face here has less to do with health care and everything to do with the overall state of the economy and government," said Rep. Anthony Weiner, a New York Democrat. "I have seen a level of dissatisfaction and even anger that I haven't experienced in the years that I've been a member of Congress," Sen. John McCain, an Arizona Republican, told an audience at a health-care meeting in Kansas City on Monday. Although the election is still far off, political forecasters predict that Democrats could run into trouble in the 2010 midterm vote. "What we're seeing now, both in terms of numbers and the feel out there, this is how big waves feel early on," said Charlie Cook, editor of the Cook Political Report. White House spokesman Robert Gibbs dismissed any talk of political doom hanging over the president and his party. "It would be like me predicting who's going to win the World Series, not in a few months but in a year and a few months," he said Monday, adding that he will leave "extremely smart prognosticators" to "their stately craft."
August, typically a sleepy month, dealt Democrats a tough hand this year. Snafus in the federal "cash for clunkers" program -- which gave people rebates to trade in gas-guzzling cars for more fuel-efficient new vehicles -- highlighted how disorganization can hamper government plans. It was the bloodiest month for U.S. troops so far in the war in Afghanistan. Attorney General Eric Holder poked a potential hornets' nest by appointing a prosecutor to investigate Central Intelligence Agency interrogators. And White House budget forecasters said they now project $9 trillion of additional federal debt over the next decade, adding $2 trillion to an earlier estimate. Last year's election gave Democrats a mandate for big changes that they feel still applies. They won seats by arguing that Republicans had failed to act to keep the housing market and financial system from crumbling. Mr. Obama also inherited a large budget deficit and expanded it further with economic-stimulus spending. Many town-hall attendees cite the deficit as a reason for holding off on health care, even though Mr. Obama and other Democrats say they won't pass a plan that adds to the national debt. Current proposals would cost about $1 trillion over 10 years, mostly to expand coverage to the nation's uninsured. All proposals aim to be deficit-neutral, offsetting new spending with cuts and some new taxes. Anger over financial bailouts, including the Troubled Asset Relief Program begun under the administration of former President George W. Bush, has been especially strong. At a meeting in Wheeling, W.Va., Democratic Rep. Alan B. Mollohan said a health-care bill was needed to help "folks in terrible situations." A member of the audience yelled out: "Use TARP funds!" In South Sioux City, Neb., last week, Van Phillips took the microphone to ask Democratic Sen. Ben Nelson how America can pay for a health overhaul with all the other programs going on.
"We've got a pretty good chunk out there already in the stimulus. We just came back with the cash for clunkers," said Mr. Phillips, a retired superintendent of schools. "I guess I'm concerned -- how do we make all of this flow?" Democrats concede they are fighting the perception that government is overstretched, though they say the economic stresses actually make a health-care overhaul more important because Democratic plans would help people who lose employer-provided health insurance. Mr. Weiner said the crowded legislative calendar and a bruising battle in June over a climate bill narrowly approved by the House is wearing down Democrats, particularly those in the fiscally conservative Blue Dog coalition. "We had a lot of House members who cast a tough vote on energy, and thought they could catch their breath, only to have health care bear down on them," he said. Rep. Chris Van Hollen (D., Md.), chairman of the Democratic Congressional Campaign Committee, said, "I've warned our colleagues from day one back in January, this is going to be a very challenging cycle. You just have to look historically....We're pleased people are being shaken out of their complacency." Other analysts think any forecast this early is overblown. "A year is an eternity, maybe two eternities, in politics," said Nathan L. Gonzales, political editor of the Rothenberg Political Report. But Mr. Gonzales agreed that skepticism about too much action in Washington can drive voters. Anger about the government led to broad Democratic gains in 2006 and 2008, and now that Democrats are running the government, activism has only increased, he said. "What we're seeing here is this larger debate about what the role of government is," said William McInturff, a Republican pollster who conducts The Wall Street Journal/NBC News poll. "The health-care debate is at that fault line.—Louise Radnofsky and Neil King Jr. contributed to this article.
Write to Janet Adamy at janet.adamy@wsj.com and Jonathan Weisman at jonathan.weisman@wsj.com
Showing posts with label Health care. Show all posts
Showing posts with label Health care. Show all posts
Tuesday, September 1, 2009
Thursday, April 30, 2009
Swine flu: 'All of humanity under threat', WHO warns
By Murray Wardrop
30 April 2009
The Telegraph, UK
The World Health Organisation has warned that "all of humanity is under threat" from a potential swine flu pandemic and called for "global solidarity" to combat the virus. The plea came as the WHO raised the swine flu threat awareness level to 5 out of 6, indicating that the world is on the brink of a pandemic. Holland and Switzerland both confirmed their first cases of swine flu on Thursday, bringing the total number of countries affected around the world to 11.
In Mexico there have been eight confirmed deaths from the virus, with another 160 suspected swine flu fatalities. There have been 93 confirmed cases in the US, 19 in Canada, 13 in New Zealand, five in Britain, four in Germany, 10 in Spain, two in Israel, and one in Austria.
The US has confirmed the first death outside of Mexico on Wednesday, while a further "probable" case of swine flu has emerged in Glasgow, Scotland's First Minister Alex Salmond told MSPs today. The new case is someone with travel links to an affected area, but he also disclosed that Iain and Dawn Askham - the first confirmed cases of the disease - had now been released from Monklands Hospital in Lanarkshire, where they had been receiving treatment in an isolation ward. Dr Margaret Chan, the WHO director-general, urged all countries to activate their pandemic plans as she made the announcement on Wednesday night. Phase 5 indicates that there is evidence of the virus being spread from human-to-human in at least two countries in one WHO region. Phase 6, the pandemic phase, is characterised by increased and sustained transmission in the general population. Dr Chan said that the world was better prepared for an influenza pandemic than at any time in history.
However, she warned that the threat "must be taken seriously" due to the ability of the swine flu swine flu virus to spread rapidly across the world. Dr Chan said that raising the phase of alert was a signal to governments, health officials and the pharmaceutical industry to take urgent action in readiness to tackle a pandemic. Speaking at a conference in Geneva, Dr Chan said: "Above all this is an opportunity for global solidarity as we look for responses and solutions that benefit all countries, all of humanity. "After all it really is all of humanity that is under threat during a pandemic. "The international community should treat this as a window of opportunity to ramp up preparedness and response. "Influenza pandemics must be taken seriously, precisely because of their capacity to spread rapidly to every country in the world. "For the first time in history we can track the evolution of a pandemic in real time. Influenza viruses are notorious for their rapid mutation and unpredictable behaviour. "All countries should immediately now activate their pandemic preparedness plans. Countries should remain on high alert for unusual outbreaks of influenza-like illness and severe pneumonia." She added: "Based on assessment of all available information and following several expert consultations, I have decided to raise the current level of influenza pandemic alert from phase 4 to phase 5. "This change to a higher phase of alert is a signal to governments, to ministries of health and other ministries, to the pharmaceutical industry and the business community that certain actions now should be undertaken with increased urgency and at an accelerated pace."
The announcement came on the same day that the Prime Minister Gordon Brown disclosed that there are now five confirmed cases of swine flu in Britain. Among them is a 12-year-old girl from Devon, who recently flew back to Britain on the same flight as the first two people who tested positive for the virus – Scottish couple Dawn and Iain Askham. The news prompted the closure of the girl's secondary school in Paignton, Devon, and 200 pupils there have been prescribed the antiviral drug Tamiflu. In response to the WHO's alert, Professor Sir Liam Donaldson, the Government's Chief Medical Adviser, said that Britain was well prepared for a pandemic.
Sir Liam said: "Phase five indicates that WHO considers a global pandemic to be imminent, whereas at phase four a global pandemic is not inevitable. "A change to phase five is a signal to countries' governments to ramp up their pandemic preparations – which we are already doing.
"We have been planning for a situation like this for some years. The preparations we have in place and are continuing to make will help to ensure we respond well in the event of a pandemic.
"If you have returned from an affected area and have flu like symptoms stay at home, call your GP or NHS Direct and you will be assessed and receive treatment if necessary." The UK will see "many more cases" of swine flu as the virus spreads but most people will make a good recovery, the Government's Chief Medical Officer said today. He told BBC Breakfast on Thursday : "Most people who get flu, even a new strain of flu, will make a good recovery. It's a nasty illness but it's short and they will recover. "To put things in proportion, in any flu, even the seasonal flu, there are some deaths, often of elderly people and the very frail. "What we will see is many more cases, but on the whole most people make a good recovery from flu." But bacteriology expert Professor Hugh Pennington, of the University of Aberdeen, said the WHO may have raised the level to five slightly prematurely to keep everybody as alert as possible. He said: "A five is where there's good evidence of transmission outside of one country and we're a little bit short of that. "I suspect they just want to keep everybody on their toes. "They are only one short of a pandemic but there has got to be very good evidence of transmission outside of where the virus started for it to be a pandemic.
"There are various definitions of a pandemic but the consensus view would be worldwide spread affecting all ages." He added that if swine flu does reach pandemic levels the scenario might not be as bad as people expect. He said: "We've been thinking of pandemic as shock, horror, millions of people will die. "Of course it may not be quite as bad as that. It may still be a pandemic with an ordinary flu virus that affects a lot of people and will still unfortunately kill people that are in the high risk groups." He said it could take four or five months to develop a vaccine against the virus. The WHO's Dr Chan explained that the decision to raise the awareness level from 4 to 5 was taken because evidence had emerged of human-to-human transmission in Mexico and the US, which are in the same WHO region. Evidence of human-to-human transmission has also been seen in Spain. With an elevated pandemic alert level, WHO might also issue travel advisories, warning against non-essential travel to regions battling outbreaks, trade restrictions, the cancellation of public events or border closures.
Thursday, April 9, 2009
Why "quality" care is dangerous...
The Wall Street Journal
April 5, 2009
By JEROME GROOPMAN and PAMELA HARTZBAND
The Obama administration is working with Congress to mandate that all Medicare payments be tied to "quality metrics." But an analysis of this drive for better health care reveals a fundamental flaw in how quality is defined and metrics applied. In too many cases, the quality measures have been hastily adopted, only to be proven wrong and even potentially dangerous to patients. Health-policy planners define quality as clinical practice that conforms to consensus guidelines written by experts. The guidelines present specific metrics for physicians to meet, thus "quality metrics." Since 2003, the federal government has piloted Medicare projects at more than 260 hospitals to reward physicians and institutions that meet quality metrics. The program is called "pay-for-performance." Many private insurers are following suit with similar incentive programs. In Massachusetts, there are not only carrots but also sticks; physicians who fail to comply with quality guidelines from certain state-based insurers are publicly discredited and their patients required to pay up to three times as much out of pocket to see them. Unfortunately, many states are considering the Massachusetts model for their local insurance.
How did we get here? Initially, the quality improvement initiatives focused on patient safety and public-health measures. The hospital was seen as a large factory where systems needed to be standardized to prevent avoidable errors. A shocking degree of sloppiness existed with respect to hand washing, for example, and this largely has been remedied with implementation of standardized protocols. Similarly, the risk of infection when inserting an intravenous catheter has fallen sharply since doctors and nurses now abide by guidelines. Buoyed by these successes, governmental and private insurance regulators now have overreached. They've turned clinical guidelines for complex diseases into iron-clad rules, to deleterious effect. One key quality measure in the ICU became the level of blood sugar in critically ill patients. Expert panels reviewed data on whether ICU patients should have insulin therapy adjusted to tightly control their blood sugar, keeping it within the normal range, or whether a more flexible approach, allowing some elevation of sugar, was permissible. Expert consensus endorsed tight control, and this approach was embedded in guidelines from the American Diabetes Association. The Joint Commission on Accreditation of Healthcare Organizations, which generates report cards on hospitals, and governmental and private insurers that pay for care, adopted as a suggested quality metric this tight control of blood sugar. A colleague who works in an ICU in a medical center in our state told us how his care of the critically ill is closely monitored. If his patients have blood sugars that rise above the metric, he must attend what he calls "re-education sessions" where he is pointedly lectured on the need to adhere to the rule. If he does not strictly comply, his hospital will be downgraded on its quality rating and risks financial loss. His status on the faculty is also at risk should he be seen as delivering low-quality care.
But this coercive approach was turned on its head last month when the New England Journal of Medicine published a randomized study, by the Australian and New Zealand Intensive Care Society Clinical Trials Group and the Canadian Critical Care Trials Group, of more than 6,000 critically ill patients in the ICU. Half of the patients received insulin to tightly maintain their sugar in the normal range, and the other half were on a more flexible protocol, allowing higher sugar levels. More patients died in the tightly regulated group than those cared for with the flexible protocol. Similarly, maintaining normal blood sugar in ambulatory diabetics with vascular problems has been a key quality metric in assessing physician performance. Yet largely due to two extensive studies published in the June 2008 issue of the New England Journal of Medicine, this is now in serious doubt. Indeed, in one study of more than 10,000 ambulatory diabetics with cardiovascular diseases conducted by a group of Canadian and American researchers (the "ACCORD" study) so many diabetics died in the group where sugar was tightly regulated that the researchers discontinued the trial 17 months before its scheduled end. And just last month, another clinical trial contradicted the expert consensus guidelines that patients with kidney failure on dialysis should be given statin drugs to prevent heart attack and stroke. These and other recent examples show why rigid and punitive rules to broadly standardize care for all patients often break down. Human beings are not uniform in their biology. A disease with many effects on multiple organs, like diabetes, acts differently in different people. Medicine is an imperfect science, and its study is also imperfect. Information evolves and changes. Rather than rigidity, flexibility is appropriate in applying evidence from clinical trials. To that end, a good doctor exercises sound clinical judgment by consulting expert guidelines and assessing ongoing research, but then decides what is quality care for the individual patient. And what is best sometimes deviates from the norms.
Yet too often quality metrics coerce doctors into rigid and ill-advised procedures. Orwell could have written about how the word "quality" became zealously defined by regulators, and then redefined with each change in consensus guidelines. And Kafka could detail the recent experience of a pediatrician featured in Vital Signs, the member publication of the Massachusetts Medical Society. Out of the blue, according to the article, Dr. Ann T. Nutt received a letter in February from the Massachusetts Group Insurance Commission on Clinical Performance Improvement informing her that she was no longer ranked as Tier 1 but had fallen to Tier 3. (Massachusetts and some private insurers use a three-tier ranking system to incentivize high-quality care.) She contacted the regulators and insisted that she be given details to explain her fall in rating. After much effort, she discovered that in 127 opportunities to comply with quality metrics, she had met the standards 115 times. But the regulators refused to provide the names of patients who allegedly had received low quality care, so she had no way to assess their judgment for herself. The pediatrician fought back and ultimately learned which guidelines she had failed to follow. Despite her cogent rebuttal, the regulator denied the appeal and the doctor is still ranked as Tier 3. She continues to battle the state. Doubts about the relevance of quality metrics to clinical reality are even emerging from the federal pilot programs launched in 2003. An analysis of Medicare pay-for-performance for hip and knee replacement by orthopedic surgeons at 260 hospitals in 38 states published in the most recent March/April issue of Health Affairs showed that conforming to or deviating from expert quality metrics had no relationship to the actual complications or clinical outcomes of the patients. Similarly, a study led by UCLA researchers of over 5,000 patients at 91 hospitals published in 2007 in the Journal of the American Medical Association found that the application of most federal quality process measures did not change mortality from heart failure. State pay-for-performance programs also provide disturbing data on the unintended consequences of coercive regulation. Another report in the most recent Health Affairs evaluating some 35,000 physicians caring for 6.2 million patients in California revealed that doctors dropped noncompliant patients, or refused to treat people with complicated illnesses involving many organs, since their outcomes would make their statistics look bad. And research by the Brigham and Women's Hospital published last month in the Journal of the American College of Cardiology indicates that report cards may be pushing Massachusetts cardiologists to deny lifesaving procedures on very sick heart patients out of fear of receiving a low grade if the outcome is poor. Dr. David Sackett, a pioneer of "evidence-based medicine," where results from clinical trials rather than anecdotes are used to guide physician practice, famously said, "Half of what you'll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half -- so the most important thing to learn is how to learn on your own." Science depends upon such a sentiment, and honors the doubter and iconoclast who overturns false paradigms. Before a surgeon begins an operation, he must stop and call a "time-out" to verify that he has all the correct information and instruments to safely proceed. We need a national time-out in the rush to mandate what policy makers term quality care to prevent doing more harm than good.
Dr. Groopman, a staff writer for the New Yorker, and Dr. Hartzband are on the staff of Beth Israel Deaconess Medical Center in Boston and on the faculty of Harvard Medical School.
April 5, 2009
By JEROME GROOPMAN and PAMELA HARTZBAND
The Obama administration is working with Congress to mandate that all Medicare payments be tied to "quality metrics." But an analysis of this drive for better health care reveals a fundamental flaw in how quality is defined and metrics applied. In too many cases, the quality measures have been hastily adopted, only to be proven wrong and even potentially dangerous to patients. Health-policy planners define quality as clinical practice that conforms to consensus guidelines written by experts. The guidelines present specific metrics for physicians to meet, thus "quality metrics." Since 2003, the federal government has piloted Medicare projects at more than 260 hospitals to reward physicians and institutions that meet quality metrics. The program is called "pay-for-performance." Many private insurers are following suit with similar incentive programs. In Massachusetts, there are not only carrots but also sticks; physicians who fail to comply with quality guidelines from certain state-based insurers are publicly discredited and their patients required to pay up to three times as much out of pocket to see them. Unfortunately, many states are considering the Massachusetts model for their local insurance.
How did we get here? Initially, the quality improvement initiatives focused on patient safety and public-health measures. The hospital was seen as a large factory where systems needed to be standardized to prevent avoidable errors. A shocking degree of sloppiness existed with respect to hand washing, for example, and this largely has been remedied with implementation of standardized protocols. Similarly, the risk of infection when inserting an intravenous catheter has fallen sharply since doctors and nurses now abide by guidelines. Buoyed by these successes, governmental and private insurance regulators now have overreached. They've turned clinical guidelines for complex diseases into iron-clad rules, to deleterious effect. One key quality measure in the ICU became the level of blood sugar in critically ill patients. Expert panels reviewed data on whether ICU patients should have insulin therapy adjusted to tightly control their blood sugar, keeping it within the normal range, or whether a more flexible approach, allowing some elevation of sugar, was permissible. Expert consensus endorsed tight control, and this approach was embedded in guidelines from the American Diabetes Association. The Joint Commission on Accreditation of Healthcare Organizations, which generates report cards on hospitals, and governmental and private insurers that pay for care, adopted as a suggested quality metric this tight control of blood sugar. A colleague who works in an ICU in a medical center in our state told us how his care of the critically ill is closely monitored. If his patients have blood sugars that rise above the metric, he must attend what he calls "re-education sessions" where he is pointedly lectured on the need to adhere to the rule. If he does not strictly comply, his hospital will be downgraded on its quality rating and risks financial loss. His status on the faculty is also at risk should he be seen as delivering low-quality care.
But this coercive approach was turned on its head last month when the New England Journal of Medicine published a randomized study, by the Australian and New Zealand Intensive Care Society Clinical Trials Group and the Canadian Critical Care Trials Group, of more than 6,000 critically ill patients in the ICU. Half of the patients received insulin to tightly maintain their sugar in the normal range, and the other half were on a more flexible protocol, allowing higher sugar levels. More patients died in the tightly regulated group than those cared for with the flexible protocol. Similarly, maintaining normal blood sugar in ambulatory diabetics with vascular problems has been a key quality metric in assessing physician performance. Yet largely due to two extensive studies published in the June 2008 issue of the New England Journal of Medicine, this is now in serious doubt. Indeed, in one study of more than 10,000 ambulatory diabetics with cardiovascular diseases conducted by a group of Canadian and American researchers (the "ACCORD" study) so many diabetics died in the group where sugar was tightly regulated that the researchers discontinued the trial 17 months before its scheduled end. And just last month, another clinical trial contradicted the expert consensus guidelines that patients with kidney failure on dialysis should be given statin drugs to prevent heart attack and stroke. These and other recent examples show why rigid and punitive rules to broadly standardize care for all patients often break down. Human beings are not uniform in their biology. A disease with many effects on multiple organs, like diabetes, acts differently in different people. Medicine is an imperfect science, and its study is also imperfect. Information evolves and changes. Rather than rigidity, flexibility is appropriate in applying evidence from clinical trials. To that end, a good doctor exercises sound clinical judgment by consulting expert guidelines and assessing ongoing research, but then decides what is quality care for the individual patient. And what is best sometimes deviates from the norms.
Yet too often quality metrics coerce doctors into rigid and ill-advised procedures. Orwell could have written about how the word "quality" became zealously defined by regulators, and then redefined with each change in consensus guidelines. And Kafka could detail the recent experience of a pediatrician featured in Vital Signs, the member publication of the Massachusetts Medical Society. Out of the blue, according to the article, Dr. Ann T. Nutt received a letter in February from the Massachusetts Group Insurance Commission on Clinical Performance Improvement informing her that she was no longer ranked as Tier 1 but had fallen to Tier 3. (Massachusetts and some private insurers use a three-tier ranking system to incentivize high-quality care.) She contacted the regulators and insisted that she be given details to explain her fall in rating. After much effort, she discovered that in 127 opportunities to comply with quality metrics, she had met the standards 115 times. But the regulators refused to provide the names of patients who allegedly had received low quality care, so she had no way to assess their judgment for herself. The pediatrician fought back and ultimately learned which guidelines she had failed to follow. Despite her cogent rebuttal, the regulator denied the appeal and the doctor is still ranked as Tier 3. She continues to battle the state. Doubts about the relevance of quality metrics to clinical reality are even emerging from the federal pilot programs launched in 2003. An analysis of Medicare pay-for-performance for hip and knee replacement by orthopedic surgeons at 260 hospitals in 38 states published in the most recent March/April issue of Health Affairs showed that conforming to or deviating from expert quality metrics had no relationship to the actual complications or clinical outcomes of the patients. Similarly, a study led by UCLA researchers of over 5,000 patients at 91 hospitals published in 2007 in the Journal of the American Medical Association found that the application of most federal quality process measures did not change mortality from heart failure. State pay-for-performance programs also provide disturbing data on the unintended consequences of coercive regulation. Another report in the most recent Health Affairs evaluating some 35,000 physicians caring for 6.2 million patients in California revealed that doctors dropped noncompliant patients, or refused to treat people with complicated illnesses involving many organs, since their outcomes would make their statistics look bad. And research by the Brigham and Women's Hospital published last month in the Journal of the American College of Cardiology indicates that report cards may be pushing Massachusetts cardiologists to deny lifesaving procedures on very sick heart patients out of fear of receiving a low grade if the outcome is poor. Dr. David Sackett, a pioneer of "evidence-based medicine," where results from clinical trials rather than anecdotes are used to guide physician practice, famously said, "Half of what you'll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half -- so the most important thing to learn is how to learn on your own." Science depends upon such a sentiment, and honors the doubter and iconoclast who overturns false paradigms. Before a surgeon begins an operation, he must stop and call a "time-out" to verify that he has all the correct information and instruments to safely proceed. We need a national time-out in the rush to mandate what policy makers term quality care to prevent doing more harm than good.
Dr. Groopman, a staff writer for the New Yorker, and Dr. Hartzband are on the staff of Beth Israel Deaconess Medical Center in Boston and on the faculty of Harvard Medical School.
Subscribe to:
Posts (Atom)