Schwitzer health news blog

Patients uninformed about potential harms of CT scans

Next time you see an ad promoting CT scans, look for any disclosure of potenial harms. Good luck finding any.

A study in this week's Archives of Internal Medicine (non-subscribers get free access only to an abstract), Medical Decision Making Regarding Computed Tomographic Radiation Dose and Associated Risk: The Patient’s Perspective, suggests that patients are inadequately informed about the potential risks of ionizing radiation form CT scans.

• 47% of patients believed that the decision to undergo CT imaging had been made entirely by their physician.

• Despite the amount of physician involvement in the decision to obtain a CT scan, patients knew little about ionizing radiation and the risks associated with medical imaging, which was demonstrated by the fact that only 6% of respondents knew that the radiation associated with CT increased the lifetime risk of cancer.

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Public willing to make tough health care choices

The non-profit Center for Healthcare Decisions just completed a study, What Matters Most, documenting what 1,200 Californians believe are the most important services for coverage by health insurance.

Len Nichols of the New America Foundation said, "The findings could have national influence as Congress begins deliberation on major health reform….this is perhaps the best representation we have of the public's view on a lot of these complicated issues."

“Leaders often assume that the public is not willing or capable of setting priorities for health insurance,” center executive director Marge Ginsburg said in a press release. “The fact is, when given a chance to speak up, the public is fully capable of making decisions that affect them as patients, as taxpayers and as citizens who want a role in developing a fair and affordable healthcare system.”

What did the survey show? "One thing we heard loud and clear is that the public is not willing to share high costs," Ginsburg said. "Most people said they would elect to take more areas of coverage away rather than paying higher premiums and copays. Everybody's very conscious of the fact that if you make cost sharing too expensive, it's counter-productive. It doesn't matter what wonderful things you offer in the way of coverage. If people can't afford it, they just won't use it," Ginsburg said.

The What Matters Most report can be downloaded here.

Stories on the survey appeared in California Healthline.org and in the Sacramento Business Journal.

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Patients struggle to find quality health care info

Yale cardiologist Harlan Krumholz has an important piece in the Washington Post, "Which Docs Measure Up?" (alternatively headlined online as "We Need A Consumer Reports for Doctors.") Excerpt:

"Need a new hip? A hernia repair? You're out of luck if you want to look at a doctor's track record or an institution's success rates. Results vary by surgeon and by hospital; you just have no way of knowing which one is best. And often, neither do they."

He frames the article, though, around the story of a patient who turned to him (a cardiologist) for advice after being diagnosed with prostate cancer.

"This patient had nowhere to turn to figure out which doctors and hospitals had the best results and the lowest risk of these complications. His dilemma is the same one that virtually every patient -- and the entire health-care system -- is facing: How can you measure quality in an area in which your life may be at stake?"

Of course what Krumholz didn't address was the fact that maybe this man's life wasn't at stake. A diagnosis of prostate cancer may not mean a death sentence. It may mean that you've been labeled with a "cancer" that wouldn't have killed you and that you really didn't need to know about.

What happened to the guy? Krumholz concludes:

"He went to a doctor his internist recommended. He heard that the doctor used a fancy new robotic surgery device and assumed that this meant that he was good. Six months later, he occasionally loses control of his bladder, and his sexual function is not what it was. He is left wondering whether he made the right choice. Meanwhile his experience is not being tracked to help the next person choose or the surgeon and the hospital improve."

Ah, the robot. I've found newspaper headlines that promote it in a cheerleading fashion:

• Robot doctor - surgery of tomorrow

• Da Vinci puts magical touch on the prostate

• Cancer survivors meet lifesaving surgical robot

• Robotic surgeon's hands never tremble

• Da Vinci is code for faster recovery

• Surgical Maestro

• DA VINCI ROBOT IS SURGERY WORK OF ART

• Hospital hopes robot surgery will lure patients

The last one may come closest to the truth.

And, as Krumholz points out in his Post article, how are patients to be guided? The headlines about "which docs measure up" or "we need a Consumer Reports for doctors" do not do justice to the broader discussion of quality measurement, inexplicable variations in health care across the US, and profound uncertainties that exist in much of the underlying medical science.

But Krumholz didn't write the headline, and he should be applauded for his important article - and the Post should be applauded for publishing it.

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Survey taps attitudes about health care delivery

A new NPR-Kaiser-Harvard survey reports:

• Patients generally do not ask about the costs of medical or lab tests they receive. Only 22 percent say they have done so in the past two years.

• Half of the public believes the American health system has a “major problem” with patients receiving unnecessary tests and treatments and even more, two-thirds, say the system has a major problem with “too many patients not getting medical tests and treatments they need.” But far fewer believe that they have ever experienced an unnecessary test or treatment (16%) or been undertreated (14%).

• Seven in ten Americans believe that there is not always clear scientific evidence about which treatment is likely to work best for any one patient. And about half report that they have talked to their doctor about scientific evidence (48%) or how well a treatment works compared to other less expensive treatments (46%) as reasons for their doctors’ treatment recommendations. But the public is guarded about the idea that government agencies, independent scientific bodies, or insurers could make decisions about which tests and treatments should be covered by insurance. For example, less than half (41%) would trust experts from an independent scientific organization appointed by the federal government “a great deal” or “a fair amount” to make such a recommendation.

Please note that journalists have done the weakest job - after three years of analysis on HealthNewsReview.org - in covering the costs of treatments, tests, products and procedures ---- and in quantifying their harms and benefits.

We reported last week at the Association of Health Care Journalists conference in Seattle that roughly 70% of 750 stories reviewed inadequately covered costs, benefits, and harms.

So journalism isn't helping as much as it could in helping consumers understand these issues.

By the way - HealthNewsReview.org had its THIRD ANNIVERSARY last week.

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Consumer confusion over how much a CT scan costs

Whistleblower column in Star Tribune tells important little story about how lost consumers can be in the alleged consumer-driven health care era.

The Strib should note that at 9 a.m. there are already 58 comments online about this column. They - and other US news organizations - should give more voice to the voiceless, confused and angry health care consumer.

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Ethical questions about consumer-driven health care plans and marketing thereof

The marketing of these plans makes my skin crawl. “Put the consumer in the driver’s seat…give consumers the tools to make smarter decisions.�? All noble goals. None ready for prime time yet.

Last week’s Journal of the American Medical Association published a commentary, "Consumer-Driven Health Care Might Not Be What Patients Need -- Caveat Emptor" by Robert Berenson of the Urban Institute and Christine Cassel of the American Board of Internal Medicine.

They write that the consumer-driven health care plan model "implicitly calls for a fundamental reordering of the patient-physician relationship, placing increased reliance on commercial ethics while eroding professional ethics as the guiding force for patient-physician interactions. ….

The consumer-directed health care goals of information sharing and involving patients in care decisions and in the societal need to manage scarce health care resources should be endorsed. But the notion that the way to achieve these goals is to further pit physicians and patients against one another as market suppliers and customers who aim to foster efficiency out of a competitive drive cannot be accepted.�?

Meantime, last week at Consumer Reports in New York, a group of people interested in online health communication issues listened to a panel that discussed the potential – but mostly the flaws – of one set of consumer-directed tools – the current online ratings for hospitals and doctors. For example, Avery Comarow of U.S. News & World Report, who manages the magazine’s annual “America’s Best Hospitals�? report, says they only started doing those rankings because the industry hadn’t. He talked about how “messy�? and “incomplete�? was the business of compiling these rankings. He said no online site has enough patient data to make a valid physician rating

Panelists talked about hospitals and doctors learning how to “game�? the system to make their statistics look better than they really were.

Those were just a few of the issues raised that indicate how far we are from having some of the tools that consumer-driven health plans promise.

Dr. John Santa, who heads Consumer Reports’ Health Ratings Center, says that until there’s a level playing field in the health care marketplace, true consumer-driven health care won’t exist.

Media Mill Video

Maggie Mahar has also blogged about why patients don’t use provider ratings systems and why that's “more bad news for consumer-driven health care.�?

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On-air spat between anchor and medical correspondent

Dr. Nancy Snyderman of NBC News appeared on the Today Show with Matt Lauer last week, profiling a physician-author who has written that the best science does not establish a causal link between childhood vaccines and autism.

Lauer, in a followup question, mis-spoke and called it a "casual" link - not causal. One wonders whether he truly knows what the words mean.

Snyderman talked about how the physician-author, Dr. Paul Offit (author of "Autism's False Prophets"), has received death threats. Snyderman herself said she had been physically ambushed by those who contend that vaccines cause autism.

As Snyderman was wrapping up the segment, Lauer said - in typical anchor throwaway language:
"Controversial subject ..."

Snyderman immediately shot back, "Not controversial subject , Matt. ...It's time for kids to get vaccinated. The science is the science. It's not controversial."

You can see the video here or here.

Kudos to Snyderman for educating her big-bucks anchor colleague live on-the-air.

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Patients v. Pharma

See Niko Karvounis's blog entry, "The Case of Patients v. Big Pharma." It starts:

On November 3rd the Supreme Court will hear the case of Wyeth v. Levine, which has been called the “business case of the century�?—and with good reason. In essence, Monday’s ruling will decide if patients have the right to sue pharmaceutical companies for personal injuries stemming from prescription drugs approved by the Food and Drug Administration (FDA). This is the big one, folks.

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Should hospitals have to disclose cancer treatment outcome disparities?

The journal PLoS Medicine offers an interesting online debate, "Should Informed Consent for Cancer Treatment Include a Discussion about Hospital Outcome Disparities?"

Studies have shown disparities in outcomes for cancer treatment from hospital to hospital. Research suggests it's another case of "the more you do, the better you are at it." Hospitals that treat more of a certain condition have better outcomes.

The journal debate tackles the important question of whether physicians have an ethical obligation to inform patients of hospital outcome disparities for cancer treatment.

One published opinion is that such disclosure "is essential to maintain trust and honesty in the physician–patient relationship. More importantly, it will protect the cancer patient's autonomy and sense of control, a value of paramount importance for a patient battling a potentially lethal disease."

But another author writes that these "arguments do support a responsibility on the part of surgeons and hospitals to track their own complication rates and disclose these data accurately and understandably in the consent process for procedures. Competent adult patients may then decide whether the benefits and risks are compatible with pursuing the procedure. However, the ethical responsibility of hospitals to discuss other institutions' outcomes is still indeterminate. Selection of treatment site is, at this point, best done as part of a dynamic decision-making process in which all aspects of treatment can be evaluated in the context of the patient's preferences, including the importance of local treatment, differences in outcomes, existing relationships with surgeons, and other intangible considerations."

In the background, I just keep thinking about the marketing of "consumer-driven health care" and I think, "Yeah, right, like this is ever going to happen - 'surgeons and hospitals tracking their own complication rates and disclosing these data accurately and understandably in the consent process for procedures.' "

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Health care horror story of the day

The California Nurses Association maintains a website, the Guaranteed Healthcare Blog, that posts a new case study of someone's personal health care/insurance disaster story almost every day.

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Waiting for medical test results

Jessie Gruman, president of the Center for the Advancement of Health, writes about "test anxiety" in her recent newsletter. Excerpts"

"Have you ever spent the weekend awaiting results of a medical test -- to confirm a cancer diagnosis, for example -- after the doctor failed to call Thursday as promised and didn’t return your calls on Friday? Gives new meaning to the idea of “the endless weekend.�?

When I ask people about their health care, one topic that comes up repeatedly is when and how they receive the results of medical tests. The situation described above is too common. But so are lost results, dangerous conditions that were detected but never reported to patients and general bewilderment about what the test results actually mean. ...

I would welcome a piece of paper that says the following:

“This is how we handle tests here:

* We expect to receive the results within 5 days.
* We will notify you within 3 days of their receipt by (select one)
o a) e-mail
o b) telephone – direct contact
o c) telephone voicemail

We will give you information about whether and how to follow up with the doctor at this time.

* We will send you a copy of the test report within a week of receipt of the results including a brief explanation of the purpose of the test and the meaning of the results.
* If you have questions, need to expedite this process or if you do not hear from us by X date, please call Patricia at this number.�?

While this piece of paper won’t ensure accurate testing, competent interpretation or a clear course of action based on my test results, it does tell me some of the steps I need to take to be a competent participant in my own care."

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Have Insurance, Need Access

See Maggie Mahar's thoughtful column, Americans Who Have Insurance —But Still No Access To Care.

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What we pay for health care administrative costs!

This entry is about an episode in my personal life - something I don't normally choose to do. I'm not trying to arbitrate a health insurance dispute in public. But this silly little episode is an example of the tremendous waste in our current health care non-system. And that's why I'm sharing it here.

My wife has received three payment notices in the mail from Fairview Health Services of Minneapolis for a $10 co-payment that she actually paid. One notice came while we were out-of-state at a funeral.

Think about what it takes to send three pieces of mail. People. Paper. Postage. All over a $10 co-pay which she actually HAD paid. The last notice threatened action by a credit agency to strong-arm her.

The patient in this case did nothing wrong. She paid the co-pay. The arrangement between the insurer and the provider was at fault.

Now think about how many times this happens each day with errors made in billing, and with patients bullied and threatened by screwups in this labyrinth of inefficiency and waste that we call the US health care system.

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Lessons about consumer-driven health plans

A column in U.S.News & World Report reflects on how high-deductible, so-called consumer-driven health plans "often end up costing consumers more out-of-pocket than they can afford, especially if they actually, you know, get sick and need to use them."

The column says "the plans are complicated: You've got your high-deductible plan, with its myriad coverage rules and limitations, and then you've got the tax-advantaged health savings account that goes along with it, which has its own raft of rules."

The column also references a paper published by the Employee Benefit Research Institute and Behavioral Research Associates on healthcare lessons that can be learned from the transition to 401(k)'s. Excerpts:

* More choice is not always better.

* When a complex decision needs to be made, people oversimplify it by reducing it to one key factor that they can get their heads around. In healthcare, that's often the monthly premium. But opting for a low monthly premium could mean that you pay much more out-of-pocket in the long run.

* Education doesn't necessarily lead to action. You may know what you should do, but that doesn't mean you'll do it. There's a lot of talk about the lack of informational tools to help people in consumer-driven health plans make smart choices based on quality or cost-effectiveness. But according to this paper, when workers at one company were given comprehensive educational tools explaining their retirement plan and how to invest, only a tiny fraction actually followed through on their intentions to enroll in the 401(k) or change the funds they invested in, among other things.

* Financial incentives like tax breaks don't necessarily motivate people to act in their best interests, either. We see this already with consumer-driven plans: Even though contributions to a health savings account are tax free, 42 percent of people who are covered by a health plan that qualifies them to open an HSA don't do so.

It's too soon to know whether consumerism, as it's called, will reshape the healthcare landscape. If it doesn't lead to lower healthcare spending, it may join tightly managed care on the scrapheap of ideas that didn't pan out as employers and others hoped, at least partly because they proved to be unpalatable to the consumers who were supposed to embrace them.

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Wisdom of the crowd re: kids & cholesterol

Some user comments responding to the New York Times website story yesterday on the American Academy of Pediatrics recommending wider cholesterol screening for children and more aggressive use of cholesterol-lowering drugs starting as early as the age of 8 show the ire and the wisdom of the crowd. Examples:

• "This is ridiculous."
• "Wow, this is just so wrong in so many ways. Shamefully!"
• "Yes, it was about time this as of yet unexplored market were tapped. We already have kids on Ritalin, so why not Lipitor, too?"
• "I think a good healthy breakfast for a child should consist of:
- Ritalin
- statins
- Prozac
- etc.
But isn’t age of 8 too late?"
•"This is scary."
• "Why not just treat the entire human population with prophylactic statins; we can start babies on the drug right from birth so that nobody will have plaque in their arteries."
• "Shocking. No evidence that statins at such a young age will benefit. As we know, children are not “little adults�?.
• "Have we lost our minds?"
• "Pure Rubbish! Voodoo science brought to you by the pharmaceutical industry. I wonder how much money they paid the good doctors to spread this junk."

Read the rest yourself.

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"Bypass brain" or "pump-head"

It was about 13 years ago when I first I heard heart surgeons talk about what they called "pump head." They were talking about the cognitive deficits that they had seen among people who had heart bypass surgery. People who were once very sharp suddenly couldn't remember where they left their keys, or couldn't balance a checkbook. But I also learned that many people were never told about this possible complication before they had the surgery.

Today, a Wall Street Journal column addresses the phenomenon, building on the speculation that Bill Clinton became a pump-head after his heart surgery - something his aides deny.

The WSJ reports:

"Symptoms include short-term memory loss, slowed responses, trouble concentrating and emotional instability. In a landmark study published in the New England Journal of Medicine in 2001, researchers at Duke University Medical Center tested 261 patients before and after bypass surgery and found that 53% of them had significant cognitive decline when they were discharged -- and 42% still suffered from it five years later.

One explanation is that when a patient's blood is pumped through a heart-lung machine during bypass, tiny air bubbles, fat globules and other particles may enter the bloodstream. The pump can also damage platelets, which form clumps, and clamping the aorta loosens bits of plaque. That debris can travel to the brain and clog tiny capillaries, forming microscopic strokes."

Bottom line: in a true shared decision-making encounter, a physician should talk about the possibility of pump head or bypass brain with anyone considering bypass surgery.

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The inexact science of projecting survival time

I am always amazed when friends and relatives use literal interpretations of a doctor's statement that "Joe has 6 months to live." If it turns out that Joe lives 5 months and 29 days, they feel robbed. If he lives 6 months and two days, he is an amazing fighter - maybe even a miracle.

Carl Bialik, "The Numbers Guy" of the Wall Street Journal has a column today on this "very inexact science" of projecting survival times.

Please read it.

It's a very important discussion that should help patients and their families form more realistic expectations when they ask or are told "how long has he got to live."

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Even a physician knows right from wrong

A physician writes this "letter of the day" in the Star Tribune:

"Pardon me, but I can't stop laughing about Dr. William McGuire's defense of his backdating stock options from UnitedHealth Group. He was simply following the advice from his legal and financial advisers.

His advisers state that he has no formal training in finance, accounting or law. They state that his only professional training is as a medical doctor.

Well, excuse me. My only professional training is also as a medical doctor.

However, even I would know it's not a good idea to accumulate millions of dollars by robbing banks or by backdating stock options. Let the trial begin."

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The whining dinosaur questions children's hospital turf wars

I'm not a big fan of hospital rankings - the kind US News & World Report does each year, for example.
But they do give some food for thought - and they certainly fed the inquisitiveness of Professor Bill Gleason of the University of Minnesota. Professor Gleason - who calls himself Mr. Bonzo (or the Whining Dinosaur) - writes on his blog about the Twin Cities market's medical arms race involving children's hospitals. And he uses the USNWR rankings to question duplication of services, and to question advertising by the University of Minnesota/Fairview Children's Hospital.

There has been surprisingly little public discussion and local news attention about this children's hospital turf war. He may be a Whining Dinosaur, but Mr. Bonzo is filling a void by keeping this issue alive - at least for anyone who finds his blog.

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Connecting the dots in health care reform news

As we flip the calendar over from a very busy May into a sunny June, I want to reflect on the common themes in the blog entries of the past four days:

1. My PLoS Medicine article, “How Do US Journalists Cover Treatments, Tests, Products and Procedures? An Evaluation of 500 Stories.�?

2. The Commonwealth Fund analysis on variations in child health care across the US.

3. Another "more care isn't always better care" study - this time in JAMA.

4. Consumer Reports releasing an online tool using Dartmouth Atlas data to allow you to look at aggressive vs. conservative care - comparing hospitals on this scale.

Connect the dots. Jack Wennberg's work rings through these themes.

Inexplicably widespread variations exist in the way health care is practiced in this country and more data comes in every day. More evidence also comes in every day that "more and newer isn't always better" in health care. And journalists are spending too much time on the "more" and the "newer" rather than on questions of evidence, costs, quality and access to care.

As a result, many consumers aren't getting much smarter at a time when some policymakers, employers and insurance company marketing folks push "consumer-driven health care" plans. Americans don't know what they're buying with the health care dollar and giving them more "skin in the game" doesn't make them smarter - only makes them hurt more - if they're not educated in the dots.

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Taking consumer-driven medicine to new depths

Maggie Mahar and Niko Karvounis on the HealthBeatblog.org write about direct-to-consumer ads taking "consumer driven medicine" to "absurd heights." Or depths. Excerpts:

"In a piece titled “Crossing the Line in Consumer Education?�? that will appear in the May 22 issue of The New England Journal of Medicine (NEJM), Drs. William E. Boden, and George A. Diamond tackle the issue, arguing that a new campaign to peddle medical devices directly to patients warrants close scrutiny. Manufacturers are inviting consumers to decide not only what is best for them, but what is best for their surgeons. This is “consumer-driven medicine�? at its most dangerous.

Boden and Diamond focus on a 60-second television spot for Johnson & Johnson’s drug-eluting coronary stent, “the Cypher,�? which debuted during last year’s Thanksgiving match-up between the Dallas Cowboys and the New York Jets. (Click here to view the advertisement in question).

The commercial has all of the hallmarks of the drug industry’s highly polished DTC advertising: First, we’re introduced to “the tough guy�? – a once-powerful man who now is “cornered by chest pains�? and sits slumped in his arm chair. Then, we are shown how he can reclaim his life in a montage of joyous physical activity accompanied by upbeat music. Of course, “this product isn’t for everyone,�? we’re told. But “life is wide open. It all depends on what you’ve got inside.�?

In the campaign to put the health care “consumer�? in the driver’s seat, where he can have “control�? and “choice,�? J&J is breaking new ground. This ad isn’t for a pill that you buy in a pharmacy but rather for a coronary stent, a wire mesh device that is placed in an artery which has been blocked by fatty deposits. Doctors first thread a tiny balloon into the artery and inflate it to clear the blockage; then they insert a stent into the artery, and a second balloon expands the stent to keep the newly cleared blood vessel wide open.

“Unlike a drug,�? Boden and Diamond point out, “whose use merely requires an office visit to a physician and a prescription the patient can fill at a pharmacy, a specialized medical device such as a stent can be selected and implanted only by someone with a very sophisticated medical understanding that no member of the lay public could realistically expect to gain from a DTCA campaign.�?

This is an important point. It’s bad enough that some patients are now sold drugs via a sound-bite, but it is even more pernicious to pretend that the pros and cons of a medical device can be condensed into a 30-second spot. ...

One last question: even if patients get the Cypher they want, what happens when they develop a blood clot? Who is responsible then?"

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Protesting off-label drug promotion

In his blog yesterday, Merrill Goozner wrote how "Patients Protest Promiscuous Promotion of Off-Label Prescribing."
Excerpt:

A coalition of consumer groups later today will send a scathing letter to the Food and Drug Administration protesting a proposal to give manufacturers a blank check to promote the off-label use of drugs and devices. The letter, signed by Consumers Union, the Center for Science in the Public Interest, the Government Accountability Project and a half dozen other patient and consumer groups, charges the lenient guidelines will undermine the FDA's authority to regulate off-label marketing and lower incentives for firms to conduct rigorous clinical trials or seek agency approval for the uses to which the drugs are being put.

The guidelines mark a "180-degree reversal of prior practice (by) eliminating Food and Drug Administration review of articles that manufacturers plan to distribute to physicians. As a weak and dangerous alternative, the draft guidance proposes a de minimus self-regulating standard," the letter asserts.

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Four related stories in one day – impact of the drug ad assault

In an interesting piece of work, MIT’s Dan Ariely reports on research that suggests that people given identical pills receive greater pain relief from the one they think costs more. He says this might explain why people lack confidence in generic pills and believe that more expensive brand name equivalents work better.

Meantime, Reuters reports that generic drug use may have slowed the growth of U.S. prescription drug costs last year to its lowest level in more than a decade.

However, USA Today reports that drug ads are pushing more Americans to ask their doctors about drugs that are advertised. And, as a result, more docs are then recommending prescriptions.

And the Associated Press reports:

“In a David vs. Goliath battle, Pennsylvania is among a handful of states trying _ with modest results at best - to counter the pharmaceutical industry's multibillion-dollar marketing and cut costs for prescription-aid programs for senior citizens, who are bombarded with "ask your doctor" advertising.�?

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Even those with health insurance get hammered

The Wall Street Journal offers a terrific and troubling profile of one man who went over his $1.5 million health insurance cap when a staph infection spread throughout his body, and was stuck with a $1.2 million hospital bill.

It's not just the 47-million uninsured who need help.

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Medicare beware

In his weekly newsletter, former U.S. Senator David Durenberger, now head of the National Institute of Health Policy writes:

“Private insurance giants United Health Group and Humana have priced 1.6 million seniors out of their current prescription drug plans. In some of the largest states in the country these top two Medicare sellers have submitted bids for 2008 which will require beneficiaries to go find other plans. …In traditional Medicare you wouldn't have this problem. It is not taking us long to find that private insurance competition is not necessarily the best nor the cheapest way for Medicare beneficiaries to access prescription drugs.

October's AARP Bulletin alerts me "Don't Fall for the Hard Sell." AARP is alerting its members to the downsides of private Medicare rather than Traditional Medicare (or "socialized medicine" as their GOP friends call it.) AARP's problem is with the hundreds of thousands of insurance agents who peddle these new plans and their prescription drug cousins to elderly folks used to dealing with Medicare as they and their parents knew it. These agents get paid a lot more for selling (the private “Medicare Advantage�?) plans than drug or medigap plans, something like $250 to $500 per sale. …Starting in January, AARP will be selling its United Health/AARP MA plan. We'll find out then what kind of "trustworthy" agents we will be dealing with.�?

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The Dangers of a "Zagat Guide" to Physicians

Read Maggie Mahar's essay on her HealthBeat Blog.

It's about how physician ratings services that look only at "trust, communication, availability, and environment" but fail to measure quality of care and health outcomes are not exactly what the patient ordered - or needs.

She concludes:

"A more credible version of what the Zagat system purports to be—a system that empowers patients to understand and manage their relationship to doctors—is the paradigm of shared decision-making.

Very briefly let me just say that: “shared decision making�? is a process which allows doctor and patient to share valuable information. First, the doctor describes the relevant risks and benefits of all treatment alternatives, and the patient shares with the physician all relevant personal information that might make one treatment or side effect more or less tolerable than others. Numerous studies indicate that when patients have the opportunity to participate in medical decision making with their physician, the patient-physician dialogue improves, and patient well-being improves as well.

This is the real deal when it comes to empowering patients to take control of their “health care decision making.�? Presumably a doctor who engages in shared decision making will score high on the metrics of trust and communication—no conflict there.

But from a long-term perspective, the reduction of medical care to Zagat snippets may be counter-productive with regards to moving toward shared decision making, because it reinforces the notion of health care as consumption. Treating doctors like restaurants perpetuates the notion that health care is like any other commodity: we want it fast and we want it now. In reality, real empowerment demands active engagement and a certain measure of personal responsibility.

The danger is that in relying on superficial measurements of service, patients will get comfortable with the quick fix approach, and we take two steps back with regards to truly integrating patients into health care as active participants."

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Cancer scare survivors

Scott Allen of the Boston Globe wrote an important story, "Cancer scares grow as screening rises." Excerpt:

"For every cancer survivor, there are several "cancer scare survivors" ... who have been told, based on imperfect tests, that they may have cancer when they do not.

False alarms are not only stressful, but they also often force patients to undergo uncomfortable follow-up tests or even surgery, only to discover that they are cancer-free. Doctors perform an estimated 2 million biopsies, in which a needle is inserted to extract a tissue sample, on healthy breasts in women and prostate glands in men each year because of suspicious test results.

In one study, more than 500 women with no symptoms of ovarian cancer underwent unnecessary abdominal surgery because a blood test wrongly suggested they had the disease.

Unfortunately, in a nation where "early detection" is a mantra and where new high-tech screening tests are being promoted for lung and breast cancer, despite high error rates, it is increasingly possible that everyone will experience a cancer scare."

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Many women misinformed on breast cancer

Judy Peres of the Chicago Tribune reports:

"As the U.S. enters National Breast Cancer Awareness Month, a new survey suggests raising awareness of the disease is a misplaced priority.

The vast majority of women already consider themselves quite knowledgeable about the disease, which is expected to kill 40,000 women in the U.S. this year. But their "knowledge" often includes more myth than fact, the survey found.

"We're surrounded by pink ribbons and other messages about raising awareness," said Fran Visco, president of the National Breast Cancer Coalition, which commissioned the survey. "But these popular efforts lull the public into a false sense that adequate progress is being made.

"There's a lot of misinformation out there," Visco said. "In order to take meaningful action, we need to educate, not just raise awareness."

One "stunning" example, she said, is that people still believe heredity is the cause of most breast cancer cases, although in reality only 5 percent to 10 percent of breast cancer is caused by genetic mutations that can be inherited.

"Women need to understand that just because they don't have a family history, that doesn't mean they're not at risk," Visco said.

The survey, being released Monday, the first day of Breast Cancer Awareness Month, also found that 7 out of 10 women believe eating enough fruits and vegetables can help prevent breast cancer. In reality, there's no good evidence that this is true.

Other findings:

Most women (and nearly two-thirds of those age 18 to 24) believe breast cancer can be prevented. In reality, there are only a few things women can do to reduce, but not eliminate, the risk of developing the disease, such as not drinking alcohol and not taking hormones. The biggest risk factors are being female and getting older.

Nearly all women believe early detection of breast cancer is important for saving lives, and 4 out of 10 think self-exam is the best way to find the disease early, the same proportion that think mammograms are the best way. But large clinical trials have shown that self-exams do not prevent death from breast cancer, although they do lead to anxiety and unnecessary biopsies.

Even mammography screening, which has been shown to reduce the risk of dying of breast cancer, is less effective than most women think, Visco said. Mammograms can be inaccurate and come with unadvertised costs, including the risk of being diagnosed and treated for a tumor that would never have caused problems.

"Women want to believe there's a way to find it early, and that finding it early is enough to save their life," Visco said.

"I understand how scary this is," she said. "We could put out messages that would comfort people, or we could tell them what the reality is. But if we don't face reality, we can't move forward and find solutions."

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A purchaser and consumer complaint

Sometimes letters to the editor capture under-the-surface citizen unrest in ways that news stories often fail to do. One such example was a letter in today's Star Tribune. It's a reader reacting to an earlier op-ed piece by a health care exec. It reads:

"As the director of a nonprofit whose employee benefits expenses for HMO medical insurance through Allina/Medica have doubled since 2000, I find it highly disturbing that part of my business costs are not allocated for health but instead are used to pay for an executive vice president of law and public policy at Allina, Mary Foarde, so she can write articles (Opinion Exchange, July 29) dismissing single-payer.

In contrast, fees I must pay per employee for Medicare do not lead to any such waste of executive expense, which is one reason Medicare -- with its single-payer structure -- is enormously popular and faces no "huge political opposition" -- in absolute contradiction to Foarde's column and other empty propaganda put forward by the self-serving, profit-driven, health care industry."

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HRT study miscommunicated by NIH?

Women have good reason to be confused by continued interpretation of the Women's Health Initiative (WHI) study on the risks and benefits of hormone replacement therapy.

The Wall Street Journal today offers an interesting inside look at how the initial findings were communicated by the National Institutes of Health (NIH).

Excerpt: "... critics including some of the WHI's own investigators, speaking out for the first time, say that NIH officials initially overgeneralized in large part because they excluded many of the study's own investigators and physicians from the first review. As a result, key questions that could have clarified the data far sooner weren't asked."

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Consumer-driven plans faltering?

The Wall Street Journal reports that despite President Bush's and big employers' push for so called "consumer-directed" health plans, consumer discomfort with the idea is rising to the surface.

The Journal speculates that "low enrollment and low satisfaction among workers who are offered them raise the question of whether consumer-directed plans will stall before they ever hit the mainstream. Few employers are focusing on the costly measures -- such as offering better coverage or more consumer education -- that may be needed to accelerate these plans."

The newspaper goes on to report:

"In a survey published last month by Towers Perrin, an employee-benefits firm, employees enrolled in them said they felt less capable of finding a quality doctor or hospital, though they often were in the same network as colleagues in other plans. Only 29% said they tried to save money in their accounts for future medical expenses.

Though the consulting firm says consumer-directed plans have much potential, its executives were surprised consumer responses were so negative.

"If I were a product manager in any other industry and saw scores this low in customer satisfaction and understanding, I'd be thinking of pulling that product from the shelves or retooling it," says David Guilmette, managing director of Towers Perrin's health-care consulting practice.

One reason for the frustration is the uphill battle many consumers describe in trying to shop for their health care."

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No surprise: Americans confused about cancer

A study in the journal Cancer Epidemiology, Biomarkers and Prevention reports widespread confusion in America about cancer and cancer prevention.

Nearly half of respondents (47.1%) agreed that "It seems like almost everything causes cancer," 27.0% agreed that "There's not much people can do to lower their chances of getting cancer," and 71.5% agreed that "There are so many recommendations about preventing cancer, it's hard to know which ones to follow."

I'm a journalist so I always look in the mirror first and I blame journalists for creating much of this confusion. The "cure" or "killer" emphasis in many stories - in order to compete for space or airtime - shows no appreciation for public understanding. Fulltime health, medical and science reporting jobs are being slashed all over the country.

Just look at how some top news organizations recently handled cancer screening stories.

And then we have health insurance marketing people shoveling "consumer driven health care plans" at us. This study is further evidence of how far away many Americans are from understanding how to be in the driver's seat of their own health care - admirable though that goal may be.

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CNN's one-sided view of mammography controversy

CNN’s House Call with Dr. Sanjay Gupta once again showed its one-sided, pro-screening bias this weekend. Excerpt:

We're starting with a change in what's been standard medical advice for a long time. For years, women over 40 have been told they need routine mammograms. Now the American College of Physicians says women with no risk factors for breast cancer should talk to their doctors first, that perhaps they could postpone their mammogram until they turn 50.

The American Cancer Society says annual mammograms starting at age 40 are still the way to go. You know what? It's leaving a lot of women wondering who they should believe.

So here to clear things up is Dr. Larry Norton. He's director of Breast Cancer Programs at Memorial Sloan-Kettering Cancer Center.

Well, Dr. Norton doesn’t accept the College of Physicians’ reasoning, writing them off as “an organization of internists�? – not cancer specialists or surgeons. He said:

"But the fact is that every woman that I speak with would much rather have a needle biopsy, which is not such a big deal, to make sure that the thing that the mammogram finds is not cancer, than actually miss a cancer that could cost her her life, or cost her her breasts."

OK, but that's personal anecdote, not evidence. There's an old saying: the plural of anecdote is not data. One big chunk of evidence he didn’t address is DCIS – or ductal carcinoma in situ – which shows up more often in earlier mammograms and leaves women confused about whether it’s a cancer, or, as it’s often called, pre-malignant or precancerous. And there is no consensus about what to do about DCIS once you find it. Why didn’t he talk about these cases? And why didn’t Gupta ask about them?

And why did Gupta and CNN only give airtime to one side of the argument? The perspective of the American College of Physicians (ACP)- the largest medical specialty organization and the second-largest physician group in the United States, representing 120,000 members - was simply not represented.

The ACP says its "clinical guidelines are developed in an explicit, rigorous process based on extensive review of available scientific evidence. They are considered 'evidence-based' rather than “expert-opinion�? or consensus guidelines. In addition to publications from the original mammography trials, ACP reviewed 117 studies to evaluate the evidence about the risks and benefits of mammography screening for women between the ages of 40 and 49."

Yet CNN didn't give ACP a voice in this segment, and let its guest get away with saying "We still need to figure out why they made this recommendation." Why not ask them on the air?

Three times in the segment, Gupta said his guest “cleared up�? the confusion. I guess it’s easy to view something as clear if you only open your mind to what you want to believe.

CNN has shown a pro-screening, evidence-be-damned mentality before. It is not balanced. It is not complete. And it is not journalism. It is advocacy.

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Health care report cards not answering the right questions

See a Boston Globe story on how health care consumers are not getting the kind of "report card" information they need when exploring health care options.

Excerpt:

"...many of the Massachusetts residents surveyed said they want information that is unavailable because it's difficult to collect or standardize comparisons between providers or has not yet been developed. Publicizing information has also met with objections from doctors and hospitals., which in some cases have has slowed the process.

In choosing a doctor, people surveyed said the most important information is the doctor's experience treating a specific medical condition, the average amount of time the doctor spends with each patient, and patient satisfaction ratings."

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Medicare Advantage sign-up dirty tricks

On the listserv of the Association of Health Care Journalists, a journalist raises an important issue that we don't hear enough about. That journalist wrote:

"May I suggest that while Washington is obsessing about Walter Reed, the rest of us should be paying attention to what’s happening in our back yards in the run-up to the deadline for switching Medicare Advantage plans? In many areas, plans have contracted with independent brokers/agents to make a last push to persuade beneficiaries to switch plans. Many broker/agents who signed beneficiaries up for one plan in the fall (to begin Jan. 1) are now urging them to switch before the deadline; that way, they collect commissions twice. There’s a lot of misinformation being spread, a lot of dirty tricks. By the time we get around to reporting on it, the March 31 deadline will have passed and the misinformation campaigns will have been successful."

Have you heard anything about this from your news organizations in your market?

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How Two Studies on Cancer Screening Led to Two Results

The headline above is the headline of an essay in the New York Times today by my former Dartmouth colleagues Gil Welch, Lisa Schwartz and Steve Woloshin. They address possible consumer confusion over how two studies - one in the New England Journal of Medicine last October and one in the Journal of the American Medical Association this month - could reach two such different conclusions on the possible benefits (and harms) of CT scan screening of smokers for lung cancer.

With their usual clarity, the three authors do a terrific job explaining how this could be - and I won't duplicate what they said here. But here's how they ended the essay:

"But neither study is definitive, because neither was a randomized trial. And both required assumptions. Given the potential benefit (so many people die from lung cancer) and the potential harms (some die from treatments), no one should have to assume anything.

Luckily, two randomized trials are under way — one a Dutch-Belgian collaboration, the other sponsored by the National Cancer Institute. Recent experience, notably with hormone replacement in postmenopausal women, has demonstrated how presuming benefits in the absence of randomized trials can cause real harm. To avoid repeating these mistakes, we should not screen for lung cancer unless the trials demonstrate a reduction in mortality."

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New drug "Havidol" - when more is not enough

Have you heard about the blockbuster new drug, Havidol?

Its creators say that HAVIDOL is for the treatment of Dysphoric Social Attention Consumption Deficit Anxiety Disorder (DSACDAD). And they say it is the only known medication available for this newly recognized disorder.

Details at Havidol.com.

It's also a spoof.

The creator of the campaign, an Australian artist, tells Reuters that many people don't get the fact this is a parody or satire. This reminds me of the spoof a few years ago on Motivational Deficiency Disorder mentioned on this blog.

I am pumped. The Havidol website tells me: "No prescription drug can promise endless happiness. However given HAVIDOL's track record, and Future PHARMS (the manufacturer) commitment to perfecting life through chemistry, terminal happiness has become a real possibility."

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To Treat Cancer, Herbs and Prayer

If you didn't see a story under this headline in the Wall Street Journal (subscription required) last week, you should.

The story descrbies "a boom in 'Christian wellness' -- dietary supplements and herbal formulas, sometimes along with diets inspired by Biblical descriptions, that sell briskly in a lightly regulated industry. Sales by religiously affiliated companies have surged since the mid-1990s to account for 5% to 10% of the dietary-supplements business, which had about $21 billion in 2005 sales, says Grant Ferrier, editor of Nutrition Business Journal in San Diego.

The products are heavily promoted on religious TV, radio and Web sites through ads featuring testimonials akin to those that evangelicals share in church services."

The story explains that "federal authorities have identified at least three dozen people who drank (one promoter's) mixtures, says a person familiar with the matter. Among those, at least eight people died of cancer, according to a Food and Drug Administration investigator's affidavit. Some patients bypassed conventional therapies for (that promoter's) regimen, according to the affidavit, patients and family members."

The boom includes such books as "What Would Jesus Eat?" and "The Bible Cure."

Of course, as the article explains, "The supplement business has boomed since passage of the 1994 Dietary Supplement Health and Education Act. Under the law, manufacturers of dietary supplements are not required to document that their products are safe or effective. The law bars makers from claiming they can treat, cure or prevent illnesses without specific FDA approval, but lets them tout benefits such as 'improved digestion.' "

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An epidemic of diagnoses

Dartmouth and VA researchers Gil Welch, Steve Woloshin and Lisa Schwartz have an essay in the New York Times that begins: "For most Americans, the biggest health threat is not avian flu, West Nile or mad cow disease. It’s our health-care system."

They go on to state: "More and more of us are being drawn into the system not because of an epidemic of disease, but because of an epidemic of diagnoses." They describe the "medicalization of everyday life," wherein "everyday experiences like insomnia, sadness, twitchy legs and impaired sex drive now become diagnoses: sleep disorder, depression, restless leg syndrome and sexual dysfunction. Perhaps most worrisome is the medicalization of childhood. If children cough after exercising, they have asthma; if they have trouble reading, they are dyslexic; if they are unhappy, they are depressed; and if they alternate between unhappiness and liveliness, they have bipolar disorder. While these diagnoses may benefit the few with severe symptoms, one has to wonder about the effect on the many whose symptoms are mild, intermittent or transient."

They look at increasing questionable use of CT scans, ultrasounds, M.R.I. and PET scans.

And they address the lower thresholds for defining disease. "Thresholds for diagnosing diabetes, hypertension, osteoporosis and obesity have all fallen in the last few years. The criterion for normal cholesterol has dropped multiple times. With these changes, disease can now be diagnosed in more than half the population."

They conclude: "Perhaps someone should start monitoring a new health metric: the proportion of the population not requiring medical care. And the National Institutes of Health could propose a new goal for medical researchers: reduce the need for medical services, not increase it."

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Consumer disenchantment with "consumer-driven" health plans

A new Kaiser Family Foundation survey of people enrolled in "consumer-driven" health plans shows that half say they would switch out of the plans if they had the chance.

The Washington Post summarized the survey. Excerpt: "More than 60 percent of people in the plans said it is hard to find good information about the cost of doctors' services and hospital care; and about 50 percent said information on quality of care is hard to come by. Half of those enrolled in the plans said they would switch out if given the choice, compared with a third of those in traditional plans. And they were twice as likely as those in traditional plans to say that they went without care because of cost.

"Instead of our health system moving towards one where we're all in this together, this type of option is leading to more splitting the population into different segments and, to me, that's an unhealthy thing," Shearer said. She added that poorer, sicker consumers could get left behind."

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Egregious spinning of lung cancer screening news

In the latest edition of The Cancer Letter (Nov. 22, 2006, Vol. 32 No. 42), Editor & Publisher Kirsten Boyd Goldberg and Editor Paul Goldberg, publish an extremely important and troubling followup to the lung cancer CT scanning study published in the New England Journal of Medicine several weeks ago. They obtained documents distributed by the the International Early Lung Cancer Action Program – or I-ELCAP - the organization that conducted the study published in the NEJM. The documents give “talking points�? to be used in media interviews about the study. Physicians who put patients on the study were urged to repeatedly use the word “compelling�? to describe the results being published, refrain from mentioning ongoing randomized trials, and urge people to get screened. The “talking points�? also urged interviewees to avoid using the terms “observational or noncomparative�? to describe the design of the trial – even though those are accurate terms for the study design, seen as a limitation by some critics.

In the article, ethicist Heidi Malm says “Why instruct other researchers not to state factual claims? This limits informed consent by suggesting that this kind of study has the same merit as other studies. [Claudia Henschke, I-ELCAP principal investigator and lead author of the study] is blocking the terms that would make it clear that it isn’t the same kind of study, so people might just assume that it has the same evidentiary quality as a randomized clinical trial. This limits informed consent from the public. They are assuming this has been shown to be effective in terms of saving lives and not just in terms of finding new cancers. It feeds into the misassumption by the public that finding more cancers is the same as saving more lives and that’s what we need the randomized trial to show.�?

I am also quoted in the article: “I consider myself well-informed on the latest methods of ‘managing the media’ by different sources in the dissemination of health, medical and science information. I consider myself quite skeptical. Yet I am shocked by what is written in these I-ELCAP ‘soundbites.’ The admonition to ‘stay on the high ground’ begs the question of ‘what is the low ground?’ To me, the low ground is the deception that is recommended in these talking points. The advice is to avoid discussing the trial design. Here are scientists urging each other to mislead journalists into doing an inferior job. The observational nature of the trial is critical to consumer understanding. But the I-ELCAP PR machine advises spokespersons to run from the truth.�?

A copy of the "talking points" spin document is included in The Cancer Letter article. While the Letter is a subscription-only publication, Editor & Publisher Kirsten Boyd Goldberg says she will send a free copy to anyone who writes to her at: kirsten@cancerletter.com.

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If only health care reform issues mattered

As Americans go to the polls today, I'm going to reflect on several items recently in the news.

Headline: "Americans Upset With Rising Health Costs". Excerpt: "Due to rising costs, Americans are falling behind in savings and struggling to handle even basic expenses, which over time has had a significant impact on their confidence in the health care system."

Headline: "Consumer Unease With U.S. Health Care Grows". Excerpt: "The U.S. health care system — touted as providing the best medical care in the world — is becoming more precarious to most Americans, who are rattled by rising costs, questions about quality and fears about the future. 'If you can afford it, it's the best health care system in the world, but, increasingly, people aren't able to afford it.' "

(Note: on the first day I visited the USA today website to read this story, it appeared alongside ads for a sleeping pill drug, a toenail fungus drug, and a new diet "as seen on 60 MInutes." Does anyone see a link between the two stories listed above, and the fact that the U.S. is one of only two countries in the world that allows direct-to-consumer prescription drug advertising?)

Headline: "U.S. Lags in Several Areas of Health Care, Study Finds". Excerpt: "The United States trails other countries in adopting electronic medical records and computerized systems to remind patients about follow-up care, prompt physicians to give patients test results and warn of potentially harmful drug interactions. It found that primary care doctors in America were less likely to have financial incentives to improve the quality of the care they provide. 'Although the U.S. pays more for health care than any other country, we are under-investing in our primary care system.' "

It's a shame that in these midterm elections, politicians didn't spend more time on the meat of these issues, instead of dragging us through more Mark Foley, more John Kerry gaffes, and an unprecedented assault on our psyche with attack ads. There is so much that could be done and needs to be done.

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Drug company astroturfing with patient advocacy groups

The New Scientist has an important article about the concerns “that some patient groups are perilously close to becoming extensions of pharmaceutical companies' marketing departments.�?

The term “astroturfing�? is used for fake grassroots campaigns created by PR professionals for special interests, spawning supposedly spontaneous upheaval of public opinion. In the case of drugs promoted by patient advocacy groups, there’s a lot of money and misinformation at stake.

The New Scientist says it “conducted the largest survey to date of industry donations to patient groups based in the US - the biggest single market for drugs and medical devices. … We selected 20 US patient groups operating on a national level with annual revenues of more than $100,000, plus five with revenues exceeding $10 million, pulling them at random from the GuideStar database, which provides information on US non-profit organisations.

Just two groups identified in New Scientist's survey - the National Women's Health Network (NWHN) and Breast Cancer Action - refuse to accept donations from pharmaceutical or medical device companies. "We want women to know that when they come to us, they are getting independent information," says Amy Allina, the network's programme director. "We think of ourselves as virtuous, but poor."

One researcher, a breast cancer survivor, concludes: "There is a tendency not to want to criticise the motives of the patient groups, because a lot of them are made up of people who are pretty seriously sick.�? She and others say that patient advocacy groups must be more transparent so that patients can make informed judgements about whom they can really trust.

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Newspaper reader: "Don't promote unproven therapies"

Sometimes you see a letter to the editor of a newspaper that you just want to frame. One such note appeared in today's Star Tribune.

The letter stated:

"Why not a more accurate headline for your Oct. 23 Business article "Massage that offers a healing message"? I suggest "St. Thomas prof sees business opportunity in quack remedy."

As an Asperger's parent, I'm tired of being treated as a sucker and cash cow for unproven remedies. When looking at possible medical treatments, businesspeople, writers, editors and "experts" owe the public the truth. If the "evidence" for effectiveness is just someone's personal story and there is no scientific rationale, it may be all right to study the treatment, but it is evil to commercialize it."

I recall reading the story in question (but was unable to find it now in the Star Tribune archives), and I recall my reaction was not far from this woman's reaction. But, as I've stated before, newspapers seem to have a different set of guidelines - and perhaps a different standard of ethics - for the Business section. There seems to be a lower standard of evidence if the story promotes any local product or company.

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Jane Pauley says she was duped on drug company ad supplement

The website, The Smoking Gun, reports that former NBC anchor Jane Pauley has sued the New York Times, claiming the paper duped her into granting an interview for what was really a drug-company advertising supplement.

The website reports: "In a lawsuit filed Tuesday in U.S. District Court, the 55-year-old broadcaster charges that she believed that the Times interview was for a news article on mental health issues, but that the story (accompanied by a full-page photo) ran in an October 2005 "special advertising supplement" promoting psychotherapeutic drugs sold by Eli Lilly and other pharmaceutical firms. Pauley, who in September 2004 disclosed her battle with bipolar disorder, alleges that the Times "duped" her into lending her name to its advertising gambit, according to the lawsuit. After going public about her bipolar disorder, the lawsuit notes, Pauley has worked with several mental health advocacy groups, including the National Mental Health Association. Pauley's lawsuit seeks unspecified damages from the newspaper and DeWitt Publishing, which helped arrange the advertorial."

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Medicare drug "doughnut hole" swallows seniors

"Every time somebody in Washington says what a wonderful benefit this is, I think they have to look a little closer."

That's what a consumer says in a Washington Post story about the millions of older Americans who are now hitting the "doughnut hole" in Medicare drug coverage. That means they've spent through the first wave of coverage are now in a hole wherein they must pay the full cost of prescription drugs - or stop taking them.

The Post reports: "Some seniors knew nothing of the coverage gap until they were hit with a bigger drug bill, advocates say.

Nine months into the program, as more and more seniors reach the threshold that puts them in the gap, many see it as a headache -- or worse."

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Employer headaches from "consumer-driven" health plans

The Wall Street Journal (subscription required) today profiles one employer's experience with high-deductible health insurance plans ("consumer-driven" as marketing folks like to call them) for his employees. The story reflects some of the good and some of the bad from this concept.

From WSJ: "The new strategy has motivated some workers to research what they are paying for medical care. One found an over-the-counter replacement for a more expensive brand-name heartburn drug. That is good news for Nick Bond, who runs the business and had suspected some employees were overusing medical care because they didn't have to pay for much of it themselves.

Mr. Bond's experience suggests that although information about the price and quality of health care remains sketchy, the president's push to make the health-care market more like the market for other services can change consumers' behavior. However, some managers have to turn themselves into instant experts both on health care and on the law. Mr. Bond knows about a transmission rebuilder's heartburn, a technician's blood-pressure medication and a visit to the emergency room by a mechanic's daughter. If he uses health information in firing or demoting an employee -- or is perceived to do so -- he might be in for a lawsuit."

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Americans ask "Why can't we get drugs from Canada?"

A Wall Street Journal online/Harris Interactive poll shows that two-thirds of Americans strongly believe a law prohibiting pharmaceutical imports from Canada and other countries is intended to protect drug-company profits. Only 9% feel strongly that it helps protect Americans from potentially harmful drugs.

Other poll results:

"80% of Americans favor allowing people to import prescription drugs from Canada and other countries if they are much less expensive there.

More than three-quarters of those polled said they believe confiscating drugs at the Canadian border jeopardizes the health of some Americans, compared with 15% who disagree. And 84% of those surveyed said they agree with making it legal to import drugs from Canada if they are approved and vetted by that country's drug regulatory agency, Health Canada, compared with 9% who disagree."

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Seniors slamming into Medicare drug doughnut hole

The Minneapolis Star Tribune had an important story about seniors with Medicare drug coverage already hitting the "doughnut hole" in their coverage.

The paper reports: "Millions of Americans are nearing that gap. Nearly two-thirds of the 11.8 million beneficiaries who bought drug policies without gap coverage will hit the doughnut hole this year -- on average in the next few weeks -- according to the Kaiser Family Foundation. Simply put, the "doughnut hole" is the gap in the Part D benefit in which consumers must pay for all of their drug costs. In 2007, it will kick in after the first $2,400 in costs, with Part D coming back in to pay 95 percent of prescription costs beyond $5,451.25."

A state-sponsored senior help line reports calls from up to 450 seniors who have hit the hole and now need help paying for drugs. They report that many are shocked to hit the gap.

The paper portrays this as the second significant snafu in the program: the rocky start with much consumer confusion and now seniors worried and confused over hitting the hole so soon.

One woman, now paying $645 a month for her drugs and preparing to take a drug-buying bus trip to Canada, said in the story: "Congress was not thinking about people when it passed this law. It was thinking how they could make the drug companies and insurance companies even richer."

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Consumers can't figure out health care prices

The Chicago Tribune has a good story on how difficult it is for consumers to find out how much something in health care will cost before they agree to pursue it. And the story shows what a joke it is to discuss “consumer-driven health care�? in the current environment.

“The market just isn’t ready to deliver on the promise of these new insurance products,�? says the president of the Midwest Business Group on Health in the article.

The article told the story of several failed consumer attempts to find out pricing information. One was by a woman who is also an exec with the Wisconsin Hospital Association, who said “How are people supposed to make good decisions if you won’t give them information?�?

“This is the only industry where people are buying services without any information,�? said the executive director of the Business Health Care Group of Southeast Wisconsin in the article. “If we want people to become more engaged in thinking about what medical care costs, we have to change that.�?

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Debate over stopping menstrual periods

An interesting column in the Chicago Tribune claims there is a lack of good information for women about new options to stop or limit menstrual periods.

The columnist blames journalists for biased coverage, doctors for failing to know enough about the risks and benefits of menstrual suppression, researchers who are "more interested in fighting for their point of view in a medical journal than provided balanced information to the public," and drugmakers "who are adept at promoting only the data that will help them sell their products."

The focal point of the current debate is the pending FDA approval of an oral contraceptive, Lybrel, the latest drug proposed to suppress menstruation.

The debate raises issues of what is "natural" for women, and whether there are elements of disease-mongering in treating menstruation as a disease - promoting prescription drugs to treat or surpress what some emphasize is a natural condition.

But that also raises issues of women's freedom to avoid bleeding if they can.

Still, safety questions hang over the entire discussion.

As it is, the column suggests that "American women are likely no closer to making an informed decision about whether to halt a function so seemingly integral to their bodies."

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Consumer-driven Health Care Marketing Disguised As News

The Star Tribune bought a UnitedHealth Group news release hook, line and sinker this week. United announced the findings of a three-year study of "consumer-driven health care plans." It reported "that the cost to employers per member in a high-deductible plan declined 3 to 5 percent, while increasing 8 to 10 percent for others."

The paper provided no details of the group surveyed. How old were they? How well-educated were they? What was their average income? Was this a cherry-picked group of healthy, higher-motivated, higher-educated, better-informed, better-able-to-shop-around employees? These are essential questions. The answers were not provided.

The Star Tribune at least did note some other opinions: one that such plans are not necessarily cheaper than traditional plans for employers, and another that these results may be preliminary. But the story still tilted far too much to the insurance industry party line, that "consumers are more discerning when they are confronted with prices and are less inclined to pay for expensive visits to the emergency room to treat something basic such as a fever or an ankle sprain."

The "put-consumer-skin-in-the-game" philosophy, in the absence of sufficient tools to help consumers play the game, is wrongheaded.

In their own city, the paper could have turned to skeptics such as former U.S. Senator David Durenberger, who recently wrote: "It’s in my best interest – and that of my children and grandchildren – to live in communities of integrated health, medical and long term care systems. It is in such communities that responsibility is shared equally among consumer, professional and insurer, and where greater accountability is demanded of those whose mixed motives might conflict with serving the consumer’s primary interest. Dis-integration is the goal of consumer-driven health care and its principal supporters in the individual insurance industry."

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Media advocacy without all the facts

The New York Daily News boasts on its website about the community service it is providing with its seventh annual week-long free prostate cancer screenings.

They profile a 45-year old African-American man who came in for screening because his father was diagnosed with prostate cancer a few years ago. His race and his family history do put him at higher risk.

But then the News says that man “is one of thousands of men who have sat down for a simple blood test.�? What they don’t tell you is that most of those thousands are not at high risk of a cancer that could kill them. But the News goes on to quote a local urologist who says, "You save one person, you're doing a good job."

Yes, you are. But at what cost? The doctor and the newspaper should have explained how many men need to be screened in order to save one life. How many will have false-positive tests, telling them they have a problem when they really don’t? How many will endure the anxiety, discomfort and expense of a biopsy needlessly? And how many men who do have true elevated PSA levels actually have a cancer that will hurt them in their lifetimes?

That’s why whenever someone calls this a “simple�? test, I shudder. There’s nothing simple about it, nor about the decision to have it or decline it.

The U.S. Preventive Services Task Force doesn't recommend annual PSA screening. These are the facts that should have been provided.

But advocacy journalism is sometimes blind to the facts that people need to make good health care decisions. Rather than sponsoring week-long free screenings, the paper would provide a bigger public service by sponsoring open, balanced, evidence-based discussions of the harms and benefits of various screening tests. That would make consumers smarter. And it would hurt no one.

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More consumer reaction to UnitedHealth pay and stock options

Letters to the editor of the Star Tribune continue to come in addressing the pay and stock options granted UnitedHealth CEO Dr. Bill McGuire.

Today, James A. Berquist of LaPorte, Minnesota, writes:

"How sorry is McGuire?

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Overblown news about "breakthrough" breast cancer drug?

The April 17 release of some clinical trial data from the STAR trial, comparing raloxifene and tamoxifen to prevent breast cancer in high-risk postmenopausal women continues to be scrutinized - both for how and why the National Cancer Institute made its announcement and for how journalists covered the story.

The San Jose Mercury News profiles the response of San Francisco breast cancer specialist Laura Esserman, who says she doesn't think this comes anywhere close to being a "breakthrough." Others in this column describe the announcement as "overselling...overblown...misleading."

It's good to see the San Jose columnist scrutinize the facts and the evidence. It should have happened sooner and more often across the country on this story.

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Breast cancer advocates scrutinize news better than some journalists

I spoke to the National Breast Cancer Coalition Fund (NBCCF) this weekend as part of a panel trying to answer the question, "Do media get the breast cancer story right?"

I came away convinced that some breast cancer advocates scrutinize claims made about progress in breast cancer better than many journalists.

For example, NBCCF president Fran Visco reminded the crowd that her group pointed out the flaws in the design of the STAR trial (comparing raloxifene with tamoxifen to prevent breast cancer in high-risk postmenopausal women). She asked why the government (and journalists) rushed to release the early trial results before they were published and peer-reviewed. She asked, "Is this great news for women?" And then she answered herself by saying that no one can know because all the data haven't been reviewed.

Breast cancer survivor and author Musa Mayer also addressed the conference, recalling how, in the past, she "swallowed the hype" of many news stories "only to end up disillusioned." She recalls feeling "lied to, jerked around." She reminded listeners that "hoping is not the same as knowing...we assume success is more likely than not...we can't afford to keep adding expensive new drugs with only modest benefits."

There are many lessons that journalists and the general public could learn from these breast cancer survivors about how to demand evidence and validation.

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The 7-minute close encounter with a doctor

Last week, Dr. Peter Salgo had an op-ed piece in the New York Times entitled, "The Doctor Will See You For Exactly Seven Minutes."

"When politicians speak of America's health care needs," he writes, "they often miss an important point: the doctor-patient relationship has become frayed. Patients aren't unhappy just because health care costs too much (though they would certainly like it to be more affordable). Rather, people sense a malaise within the system that has eroded the respect they feel patients deserve."

Later in the piece he advises: "You, the patient, are the system's best hope. In the age of seven-minute health care, you need to realize that you employ doctors. That is, your doctor works for you. Although doctors shouldn't think of patients as customers, you can, and should, adopt a business mind-set when shopping for health care. Evaluate what it is you expect from your doctor, then ask for it. If you are unhappy with your doctor, fire him. If you cannot get more than a seven-minute face-to-face encounter with your doctor, he needs fewer patients. The true power in the health care economy rests not with the doctors and certainly not with the backroom business staff. It rests with you. If you insist on being treated with care and respect, you will be. And the system will improve as a result."

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Wrong incentives in "consumer-driven health care"

Jessie Gruman, Executive Director of the Center for the Advancement of Health, offers an essay on “consumer-driven health care�? on the Center’s website.

She writes that:

“Consumer-driven health care tells you it will pay 100 percent for your screening and early detection costs because you can’t be trusted to go to the doctor on your own when you feel healthy. But when you are sick and least able to make a rational decision, it tells you to make your own call on which expensive drug to take or whether to opt for surgery.

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Cracking down on 69-year old drug "criminals"

The Star Tribune reports that “Minnesotans buying mail-order prescription drugs from Canada are having medications confiscated by U.S. Customs in escalating numbers….It is unclear why federal authorities have increased confiscations now.

‘I felt like the drug companies are [calling] the shots here,’ she added. ‘They're controlling our government. I felt violated, like something was stolen from me.’ “

Think about this. Seniors are rejecting the feds’ Medicare prescription drug plan in surprising numbers. Many who accept the plan are terribly confused by how to use it. In designing the plan, the feds gave up the chance to negotiate with drug companies for lower prices. But now when a 69-year old woman (and many others like her) pursues what she thinks is a better approach for her own health and purse, her shipment is seized – like she’s a criminal.

This is one little example of why I feel ill when I hear medical marketers call this the era of consumer-driven health care.

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The high risk of consumer-driven health plans

The Washington Post offers a profile of an educated health care consumer, counsel for the Senate Finance Committee, who was "pushed to the limits of her knowledge and patience keeping track of her so-called consumer-directed health plan."

The headline of the article calls consumer-directed plans "a health gamble."

That savvy consumer said, "I appreciate the concept of making consumers more aware about health care costs," but "I didn't understand the full consequences" of choosing a high-deductible policy. She says her health plan left her confused and with a pile of paperwork. She says her experience was "awful," adding, "I don't consider it consumer-directed and it's certainly not consumer-friendly."

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Consumers lost in labyrinth of medical bills

Why do health insurers send out unintelligible statements with billing codes tha none of us can decipher? The New York Times has a good column on these questions. It includes quotes from the president's senior adviser on health information technology, who admits he can't figure out the insurance statements he receives.

Insurers call these mailings EOBs -- or explanations of benefits. Consumers may want to scream EOB -- or "end our bondage" -- in this meaningless labyrinth of paperwork. After all, isn't this the era of CONSUMER-DRIVEN HEALTH CARE, when all the informational tools will be available to consumers to help them make better choices?

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Pinkwashing with breast cancer fundraising

�Pinkwashing� is a term used to criticize corporate campaigns and practices in which the sponsoring companies position themselves as leaders in the struggle to eradicate breast cancer. But the advocacy group Breast Cancer Action, with its "Think Before You Pink" campaign, questions how and why breast cancer has become the poster child of corporate cause-related marketing campaigns, as companies try to boost their image and their profits by connecting themselves to a good cause. Breast Cancer Action urges people to ask some critical questions before opening their wallets for these marketing campaigns: How much money goes to the cause? What is it supporting? How is it being raised? And will it truly affect the fight against breast cancer?

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Doctors sue to silence angry patients' online gripes

There's an interesting story in the Wall Street Journal about the "growing number of legal battles being waged over Internet postings about medical complaints."

As the story explains, "More patients are taking their opinions of their local doctors to the Internet, and a wider audience, and that has some medical providers on edge. Several Web sites have sprung up that encourage patients to post anonymous reviews of doctors and dentists, and some frustrated patients have created entire Web sites to criticize specific physicians."

Some health care professionals are countering with lawsuits claiming libel and other things. It's an interesting story of First Amendment issues and of medical consumerism.

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Consumers concerned about too much treatment

A Wall Street Journal/Harris Interactive poll shows that "more than half of U.S. adults say they've chosen to forgo a treatment recommended by their doctor, including filling a prescription, getting a diagnostic test or undergoing a surgical procedure, because they felt it was unnecessary or too aggressive."

One of the pollsters said, "A great deal of attention has been given to public concerns about aggressive profiteering on the part of pharmaceutical companies and other sectors of the health-care industry; these findings suggest that to some extent the public is also leery of the motivations behind physicians' decisions regarding patient care."

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Informed consent problems too common

Syndicated columnist Judy Foreman has a good column on informed consent. In it, one ethicist says that too often "the ideals of informed consent get reduced to creating a paper trail for medico-legal and bureaucratic reasons." Another says that often, the informed consent process is geared to "protecting the doctor and hospital from malpractice," not empowering the patient.

Foreman includes good information on how and when the process should work, what informed consent should include, and on what consumers can do to protect themselves.

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