Sean Khozin, MD, MPH

The wheels for economic recovery have been set into motion, or at least are being lubricated, with the signing of the American Recovery and Reinvestment Act of 2009 by President Barack Obama on February 17, 2009. The plan was put together rather quickly behind closed, or at best ajar, doors.

The bill is designed to stimulate the economy, or as it’s phrased officially “to create jobs, restore economic growth, and strengthen America’s middle class through measures that modernize the nation’s infrastructure, enhance America’s energy independence, expand educational opportunities, preserve and improve affordable health care, provide tax relief, and protect those in greatest need, and for other purposes.”

Try saying that in one breath although I would be more impressed with achieving all the objectives in one lifetime.

There is a lot of money set aside for heathcare reform, with serious emphasis on health information technology. Here are the highlights:

• More than $140 billion in healthcare spending
• Increase in federal payments by $87 billion to States in order to prevent Medicare cuts
• $25 billion to cover 65% of the COBRA premium costs for lower-income workers
• $19 billion in grants and incentives for companies and medical practices to buy health information technology
• $10 billion to increase the research budget of the National Institutes of Health (NIH) on top of the agency’s $29 billion budget
• $1.1 billion dedicated to comparative-effectiveness studies at NIH and other agencies

The government is planning to hand out millions in grants to States and “State-designated entities” to promote the uptake of health information technology. Dozens of committees, even new federal agencies, are being formed to carry out the administration’s new policies. Comparative effectiveness research, where cheaper therapies are weighed against more expensive ones, will be the new buzzword. This will set the stage for the government to exert more influence over the medical decision making process, steering patients towards cheaper therapeutic alternatives that are deemed as good as their more expensive counterparts, or as it’ll most likely evolve, just good enough.

Roy Porter, the late British historian, starts his 1999 book “The Greatest Benefit to Mankind: A Medical History of Humanity” reflecting on the strangeness of our times. He observes the paradox of being healthier than ever but more anxious about our health (remember that life expectancy at the turn of the 20th century in the Western world was in the 40’s). Would the rationing of healthcare resulting from expanding coverage in the face of a shortage of healthcare providers and denying expensive therapies make us even more anxious? Maybe so, but our psychological health, and perhaps even our physical one (if you’re the cancer patient who is denied the “expensive” chemotherapy) are now secondary to the economic health of the country.

So let’s hope that the American Recovery and Reinvestment Act of 2009 accomplishes what it intends to do, i.e. to “create jobs, restore economic growth, and strengthen America’s middle class through measures that modernize the nation’s infrastructure, enhance America’s energy independence, expand educational opportunities, preserve and improve affordable health care, provide tax relief, and protect those in greatest need, …”

Acknowledging the “daunting challenges” facing our heatlhcare system today, a new McKinsey Quarterly report highlights the need for strong leadership that “must come substantially from doctors and other clinicians.” The growing concerns about many administrators being out of touch with the realities that govern taking care of patients is placing clinicians in a great position to become the pragmatic agents of transformative change.

I give my patients free generic medications as one of the benefits of being a member of my practice. I just ordered a few medications and what you see above is a screenshot of my shopping cart. You may notice that the prices aren’t listed. That’s a very common theme in healthcare. Nobody knows how much anything costs. Lack of transparency is the law of the land and the secret to maximizing returns. My drug vendor will probably look at my order history and price each item based on how frequently I order and what they’re charging other doctors in my area. This way, I won’t have the freedom to shop around for good deals.

Imagine if Amazon did the same thing when you ordered a book on their website.

Do the benefits of preventing disease outweigh the costs associated with screening large groups of people?

The answer depends on who you ask. For example, a recent article in Health Affairs by Louise B. Russell reminds us that:

Over the four decades since cost-effectiveness analysis was first applied to health and medicine, hundreds of studies have shown that prevention usually adds to medical costs instead of reducing them. Medications for hypertension and elevated cholesterol, diet and exercise to prevent diabetes, and screening and early treatment for cancer all add more to medical costs than they save.

In response to the above study, John Goodman (not the actor, but the “father of health savings accounts”), writes the following on his blog:

Does preventive care save lives? Of course. Does it save money for some patients? Definitely. But the cost of screening healthy patients outweighs the savings on patients whose diseases are caught in their early stages. Preventive medicine is desirable. But there’s no free lunch.

So if you’re the among the group whose disease is detected early by screening, you’re not only likely to save money but also live longer. Society, however, pays for all those mammograms, colonoscopies, and PSA’s that end up being negative and don’t lead to detecting disease.

So what is the right thing to do?

To screen or not to screen: that is the question.

Whether ’tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles,
And by opposing end them?

If you’d asked Frank Zappa, the genius composer who died in 1993 from advanced prostate cancer at age 52, he may have found it nobler to had been given a chance to fight. By the time they found his cancer, it had metastasized, rendering him defenseless against his outrageous fortune.

Below is Frank Zappa’s last official interview with Today Show. Fast forward to 7:26 to hear him urge the public to get tested and then retested for prostate cancer.

There’s definitely no free lunch… and no one-size-fits-all solutions. Saving lives is becoming an increasingly expensive endeavor.

This New York Times article talks about the growing moral dilemma faced by healthcare providers where “the competing demands of administrators, insurance companies, lawyers, [and] patients’ families” adversely affect what doctors and nurses believe is right for their patients.

Finally, people are starting to recognize the persistent intrusion on the ability of healthcare providers to make appropriate decisions for their patients.

A sound and comprehensive healthcare reform proposal should reduce the influence of the middleman, directly address malpractice reform, avoid creating more bureaucracy, and increase providers’ ability to make independent decisions–based on their experience and clinical judgment. Anything else would be beating around the bush.

“Make no mistake, tax cheaters cheat us all and the IRS should enforce our laws to the letter.” Tom Daschle, 1998