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  1.    #1  
    It is worth noting, maybe several times, that the ACP has nothing to do with the government but is an organization of internal medicine practitioners. ACP link

    TORONTO, April 23, 2010 -- Building on its existing foundation of clinical and public policies, the American College of Physicians (ACP) announced plans to provide physicians and patients with evidence-based recommendations for specific interventions for a variety of clinical problems. ACP’s High-Value, Cost-Conscious Care Initiative will assess benefits, harms, and costs of diagnostic tests and treatments for various diseases to determine whether they provide good value -- medical benefits that are commensurate with their costs and outweigh any harms.

    “Physicians and patients need evidence-based information so they can make the right decision about the right treatment at the right time,” said Joseph W. Stubbs, MD, FACP, President, ACP. “High-value, cost-conscious care is about eliminating overused and misused medical treatments that do not improve patient health or might even be harmful.”
    According to ACP, it is essential to assess benefits, harms, and costs of an intervention to determine whether it provides good value. Evaluation of the costs of an intervention is insufficient to assess value; inexpensive interventions may provide little value, and expensive interventions may provide good value and meet accepted thresholds for clinical and cost effectiveness.

    According to ACP’s 2009 policy paper, Controlling Health Care Costs While Promoting the Best Possible Health Outcomes, the Congressional Budget Office (CBO) estimates that 5 percent of the nation's Gross Domestic Product -- $700 billion per year -- is spent on tests and procedures that do not actually improve health outcomes. ACP contends in that paper that savings can be achieved by reducing inappropriate utilization of services and by encouraging clinically effective care based on comparative effectiveness research.
    “By eliminating medical treatments that do not directly improve a patient’s health, physicians and patients can significantly reduce waste and preserve high-quality care,” said Dr. Stubbs.
    A great example is doing routine mammograms on every woman between the ages of 40 and 49....since all the evidence published suggests there is no survival benefit to doing that when compared to the harm/risks involved.

    To re-emphasize: This is NOT the government. It is a group of practicing doctors who want to provide the most cost-effective and highest quality care to their patients.
  2. #2  
    Thank you.
  3.    #3  
    Quote Originally Posted by UntidyGuy View Post
    The recent mammogram controversy highlights how politicized these guidelines are. The US Preventive Service Task Force operated in virtual obscurity for decades until this announcement. Because of the backlash, practically every other organization in medicine ran the other way including ACOG. The USPSTF recommendation on mammograms is going to be disregarded for no other reason than it's a political hot potato. So, what use are evidence-based guidelines when we are only going to implement the ones that the public will accept?
    That's a relevant observation. The first problem with this issue is that most people who just read the headlines misinterpreted what was said. They did NOT recommend not doing mammograms in women under 50. There exact statement was as follows:
    The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
    They simply found very weak evidence that the benefit outweighed the harm in women under 50, whereas the evidence over 50 was stronger. The "other groups", such as the ACS, ACOG and the American College of Radiology all have maintained different interpretations of the data, the most cogent being that the technology has changed since the older studies were done. That doesn't mean the new technology has actually been shown to improve survival any better than the old; the studies have not been done, thus the recommendation that it is a personal decision between the doctor and patient, taking into account the patient's risk and opinions. That is quite different than saying they should not be done, or that they are harmful. It' saying there isn't enough evidence at this point to say one way or another.
    And while I hesitate to suggest duplicity, ACOG and radiology groups all benefit from increased breast cancer screening. That's just a fact. The USPSTF does not, and would have no reason to be biased in either direction. The ACS has ALWAYS been more aggressive than any other body in terms of screening (Pap smears, for instance).

    Again in my opinion, anyone could have predicted this given the concern about women's health being a major political issue, along with a medical issue. This is demonstrated by the fact that the recommendations for prostate cancer screening, which are equally unclear in terms of benefit, have met with no major uproar. Here are current recommendations for that:
    The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years.
    And this is the ACS comment:

    At this time, the American Cancer Society (ACS) recommends that men thinking about prostate cancer screening should make informed decisions based on available information, discussion with their doctor, and their own views on the benefits and side effects of screening and treatment (see below).
    Until more information is available, you and your doctor can decide whether you should have tests to screen for prostate cancer. There are many factors to take into account, including your age and health. If you are young and develop prostate cancer, it may shorten your life if it is not caught early. If you are older or in poor health, then prostate cancer may never become a major problem for you because it is often a slow-growing cancer.
    American Cancer Society recommendations for the early detection of prostate cancer
    The American Cancer Society recommends that men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer. The decision should be made after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening. Men should not be screened unless they have received this information.
    In other words, they do NOT recommend routine screening for prostate cancer.

    Most preventive care recommendations will not come with as much political baggage as mammographic screening. At least at this point in time, it is up to providers, patients and payors to determine what is covered and not covered; but those decisions are independent of the Task Force, which has no horse in any race regarding those issues, and that's the way it should be.
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    #4  
    Quote Originally Posted by davidra View Post
    To re-emphasize: This is NOT the government. It is a group of practicing doctors who want to provide the most cost-effective and highest quality care to their patients.
    I'm quite certain that the 40-49 year olds that will be dying in the near future from breast cancer will find comfort in knowing this.
    The Law of Logical Argument: Anything is possible if you don't know what you are talking about.
  5.    #5  
    Quote Originally Posted by Micael View Post
    I'm quite certain that the 40-49 year olds that will be dying in the near future from breast cancer will find comfort in knowing this.

    And what about the 20 year olds? Do you not care about them? You must also not care about the percentage of 40 to 49 year olds that will be treated for cancer unnecessarily if they are screened, or the percentage of women who will be paying for biopsies and follow-up testing when it was never needed in the first place. Why do you care so little about these people? Why don't you tell me when you want to begin screening women for breast cancer, and then tell me why you reached that conclusion. Please, by all means, enlighten.
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    #6  
    Quote Originally Posted by davidra View Post
    And what about the 20 year olds? Do you not care about them? You must also not care about the percentage of 40 to 49 year olds that will be treated for cancer unnecessarily if they are screened, or the percentage of women who will be paying for biopsies and follow-up testing when it was never needed in the first place. Why do you care so little about these people? Why don't you tell me when you want to begin screening women for breast cancer, and then tell me why you reached that conclusion. Please, by all means, enlighten.
    You're asking the wrong question. It's not "when" - its "when based on if's". Screening should be based on risk factors, and you know it. You can't just draw a line in the sand based on age. This is why it's so important that the decision on when to screen should be up to the doctor and the patient. Statistics are helpful, but it really should be case by case, and you can't legislate that from some high level board.
    The Law of Logical Argument: Anything is possible if you don't know what you are talking about.
  7.    #7  
    Quote Originally Posted by Micael View Post
    You're asking the wrong question. It's not "when" - its "when based on if's". Screening should be based on risk factors, and you know it. You can't just draw a line in the sand based on age. This is why it's so important that the decision on when to screen should be up to the doctor and the patient. Statistics are helpful, but it really should be case by case, and you can't legislate that from some high level board.
    Oh. So your suggestion is that there shouldn't be ANY recommendations (not "legislating", as you said, these are recommendations, remember?)for screening asymptomatic women? Most women are of average risk. Do you not think there should be recommendations for what to do as far as screening the 30 year old patient with average risk? Oh....and do you expect your own insurance company (you know, the one you work for) to pay for screening mammograms in an asymptomatic 25 year old woman because she and her doctor want it? How long do you think they'll be in business?

    Do you think there should be guidelines for diabetes care, for instance? Are the national societies like the ACS or ACOG or ACP wasting their time and money determining suggestions for doctors that will enable them to provide the best possible care? I guess you feel that doctors have pretty unlimited time and can keep up with all the literature and "statistics" so they can be perfectly capable of making all these decisions without any input from others, correct?

    Tell you what, ask your doctor how he or she feels about that scenario.
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    #8  
    Quote Originally Posted by davidra View Post
    Oh. So your suggestion is that there shouldn't be ANY recommendations for screening asymptomatic women? Most women are of average risk. Do you not think there should be recommendations for what to do as far as screening the 30 year old patient with average risk? Oh....and do you expect your own insurance company (you know, the one you work for) to pay for screening mammograms in an asymptomatic 25 year old woman because she and her doctor want it? How long do you think they'll be in business?

    Do you think there should be guidelines for diabetes care, for instance? Are the national societies like the ACS or ACOG or ACP wasting their time and money determining suggestions for doctors that will enable them to provide the best possible care? I guess you feel that doctors have pretty unlimited time and can keep up with all the literature and "statistics" so they can be perfectly capable of making all these decisions without any input from others, correct?

    Tell you what, ask your doctor how he or she feels about that scenario.
    There is a galaxy of difference between if and when a woman should have screening, and how and who should pay for it. You're mixing and meshing arguments.
    The Law of Logical Argument: Anything is possible if you don't know what you are talking about.
  9.    #9  
    Quote Originally Posted by Micael View Post
    There is a galaxy of difference between if and when a woman should have screening, and how and who should pay for it. You're mixing and meshing arguments.

    Yeah, you're right. If and when a woman should have screening should be determined by individual risk and whether or not the screening will benefit them more than it will harm them. Right? and if you believe that, then you certainly understand that no individual doctor can see enough patients to be able to make that determination by themselves, they have to rely on grouped data (oh, that danged "statistics" again).

    Deflecting onto the issue of payment, however, does not begin to address the other issues. Should there be clinical guidelines to help doctors decide about these things? I guess I'll have to keep asking until you provide the answer. If a woman of 30 (or 20, for that matter), with average breast cancer risk, wants a mammogram, should she have it?
    Let me give you a hint: a woman at age 30 has a 1 in 229 chance of developing breast cancer over the subsequent 10 years. That's for average risk. Now she'll get regular exposure to radiation annually if you decide to do it, and the risks of that are known. Additionally, if breast cancer is diagnosed, she also has somewhere between 7 and 50% chance of what is called "overdiagnosis", which is cellular finding of cancer that will never metatasize, but will result in her getting chemotherapy, radiation therapy, and surgery when the cancer would have never hurt in the first place. So should she have it?

    See, the issue is not about payment. It's about what the best quality of care is for the patient. That's why I can't wait to see your answer.
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    #10  
    Quote Originally Posted by davidra View Post
    Yeah, you're right. If and when a woman should have screening should be determined by individual risk and whether or not the screening will benefit them more than it will harm them. Right?
    I can't tell if you're ridiculing me here or not. Yes, that's simply all I was saying. Seems pretty black and white to me. I admit to not being anywhere near an expert.
    and if you believe that, then you certainly understand that no individual doctor can see enough patients to be able to make that determination by themselves, they have to rely on grouped data (oh, that danged "statistics" again).
    No, I don't believe that follows. At least, not how you context it. Certainly I'd think the doctor could avail himself to statistical data, probability factors, radiation risk factors, new protocols and detection methods, etc. That *is* what we pay him for, no? To advise us about the risks and to help us formulate a plan based on our individual needs?
    Deflecting onto the issue of payment, however, does not begin to address the other issues. Should there be clinical guidelines to help doctors decide about these things? I guess I'll have to keep asking until you provide the answer. If a woman of 30 (or 20, for that matter), with average breast cancer risk, wants a mammogram, should she have it?
    Yes, but again, thats not the right question. What you're really asking is who should pay for it.
    Let me give you a hint: a woman at age 30 has a 1 in 229 chance of developing breast cancer over the subsequent 10 years. That's for average risk. Now she'll get regular exposure to radiation annually if you decide to do it, and the risks of that are known. Additionally, if breast cancer is diagnosed, she also has somewhere between 7 and 50% chance of what is called "overdiagnosis", which is cellular finding of cancer that will never metatasize, but will result in her getting chemotherapy, radiation therapy, and surgery when the cancer would have never hurt in the first place. So should she have it?
    See my previous two points.... I think I've answered you?
    See, the issue is not about payment. It's about what the best quality of care is for the patient. That's why I can't wait to see your answer.
    Seems like we both want the best quality of care for *the* patient.

    My concern is that your "recommendations" board will in fact become what drives insurance policies. I think that if you really thought about it, you'd see what I'm saying is in fact a danger.... the other side of the swinging blade, so to speak?
    The Law of Logical Argument: Anything is possible if you don't know what you are talking about.
  11.    #11  
    Quote Originally Posted by Micael View Post
    I can't tell if you're ridiculing me here or not. Yes, that's simply all I was saying. Seems pretty black and white to me. I admit to not being anywhere near an expert.

    No, I don't believe that follows. At least, not how you context it. Certainly I'd think the doctor could avail himself to statistical data, probability factors, radiation risk factors, new protocols and detection methods, etc. That *is* what we pay him for, no? To advise us about the risks and to help us formulate a plan based on our individual needs?
    Yes, but again, thats not the right question. What you're really asking is who should pay for it.

    See my previous two points.... I think I've answered you?
    Seems like we both want the best quality of care for *the* patient.

    My concern is that your "recommendations" board will in fact become what drives insurance policies. I think that if you really thought about it, you'd see what I'm saying is in fact a danger.... the other side of the swinging blade, so to speak?
    Should the determination of harm play a role? If a doctor thinks that the risks are greater than the benefits for mammograms in a 20 year old woman, but she wants it anyway, should she have it? And no, this isn't about payment. People just can't seem to grasp the fact that there are some very negative things that can happen when you are inappropriately screened. More testing is not necessarily a good thing. In fact, more than not, it's a bad thing when done in the wrong group.

    Next time you see your doc, ask them the last time they looked up radiation exposure tables over time for a 20 or 30 year old woman. Please.

    Now...there is no way to decrease health care costs in this country without limiting the use of ineffective treatments and diagnostic tests. If you sprain your knee and want an immediate MRI, should you get it? The fact is that the vast majority of people do not need an MRI and will not benefit from it. They will be better in a few weeks whether they get an MRI or not. And if they're not, that might be a more reasonable time to get an MRI, right? The amount of money, estimated by the CBO in my OP, is huge. If you are not willing to do something to control that waste, then there is no solution to decreasing costs. That means that you might not get your MRI, and the healthy low-risk 20 year old might not get her mammogram, even though you both want it. If the population cannot accept that care management (I suppose you might call it "rationing". I call it high quality care) then we have no chance of avoiding economic disaster because health care costs will continue to rise without any controls...hopefully, the implementation of this health care bill will determine best practices. But it seems that regardless of what non-governmental expert group makes recommendations, you are opposed to doctors paying attention to them. Congrats....that's exactly what got us into this mess in the first place...uncontrolled spending on ineffective interventions.
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    #12  
    Quote Originally Posted by davidra View Post
    Should the determination of harm play a role?
    Of course. I agreed with that.
    If a doctor thinks that the risks are greater than the benefits for mammograms in a 20 year old woman, but she wants it anyway, should she have it?
    Interesting question. At first blush, I suppose I don't think its smart for a woman to walk in to a screening facility and ask for a jolt of radiation without first getting the ok of a doctor.... one who supposedly worked through the pre-screening process with the patient. Again, what was the point of seeing the doctor in the first place if you're not interested in his recommendations. Next you'll go to "so if the patient doesn't like to be told no, and eventually finds a doctor that will agree to sign off on a mammogram, should she get one?" Let me beat to the chase and answer - yes. Ultimately it's the patients own responsibility to make the final decision for themselves.
    And no, this isn't about payment. People just can't seem to grasp the fact that there are some very negative things that can happen when you are inappropriately screened. More testing is not necessarily a good thing. In fact, more than not, it's a bad thing when done in the wrong group.
    I grasp what you're saying, clearly. We aren't talking about 20 or 30 year old women, btw. You keep lowering that ages. Next you'll drop down to 10 to 20 year old girls.
    Next time you see your doc, ask them the last time they looked up radiation exposure tables over time for a 20 or 30 year old woman. Please.

    Now...there is no way to decrease health care costs in this country without limiting the use of ineffective treatments and diagnostic tests.
    Sure there are. There's lots of ways. You yourself helped lead the charge against the evil insurance companies. Remember?
    If you sprain your knee and want an immediate MRI, should you get it?
    If you're paying for it, or have paid for a plan that has agreed to cover it, yes.... as long as you meet pre-screen requirements? Does that help?
    The fact is that the vast majority of people do not need an MRI and will not benefit from it. They will be better in a few weeks whether they get an MRI or not. And if they're not, that might be a more reasonable time to get an MRI, right?
    Not if their injury would have benefited from earlier diagnosis.
    The amount of money, estimated by the CBO in my OP, is huge. If you are not willing to do something to control that waste, then there is no solution to decreasing costs. That means that you might not get your MRI, and the healthy low-risk 20 year old might not get her mammogram, even though you both want it.
    Ain't government healthcare grand?
    If the population cannot accept that care management (I suppose you might call it "rationing". I call it high quality care) then we have no chance of avoiding economic disaster because health care costs will continue to rise without any controls...hopefully, the implementation of this health care bill will determine best practices.
    Sure it will. That's another name for rationing and what's best for the "collective", as a whole. Down with the individual - those greedy self interested money wasters.
    But it seems that regardless of what non-governmental expert group makes recommendations, you are opposed to doctors paying attention to them.
    When did I say that? Ever? Now you're trolling.
    Congrats....that's exactly what got us into this mess in the first place...uncontrolled spending on ineffective interventions.
    Nice snarky finish. Since when did self-determination and personal choice become a liability?
    The Law of Logical Argument: Anything is possible if you don't know what you are talking about.
  13.    #13  
    Quote Originally Posted by Micael View Post
    Of course. I agreed with that.
    Interesting question. At first blush, I suppose I don't think its smart for a woman to walk in to a screening facility and ask for a jolt of radiation without first getting the ok of a doctor.... one who supposedly worked through the pre-screening process with the patient. Again, what was the point of seeing the doctor in the first place if you're not interested in his recommendations. Next you'll go to "so if the patient doesn't like to be told no, and eventually finds a doctor that will agree to sign off on a mammogram, should she get one?" Let me beat to the chase and answer - yes. Ultimately it's the patients own responsibility to make the final decision for themselves.

    I grasp what you're saying, clearly. We aren't talking about 20 or 30 year old women, btw. You keep lowering that ages. Next you'll drop down to 10 to 20 year old girls.
    Sure there are. There's lots of ways. You yourself helped lead the charge against the evil insurance companies. Remember?
    If you're paying for it, or have paid for a plan that has agreed to cover it, yes.... as long as you meet pre-screen requirements? Does that help?
    Not if their injury would have benefited from earlier diagnosis.
    Ain't government healthcare grand?
    Sure it will. That's another name for rationing and what's best for the "collective", as a whole. Down with the individual - those greedy self interested money wasters.
    When did I say that? Ever? Now you're trolling.
    Nice snarky finish. Since when did self-determination and personal choice become a liability?

    Truly amazing. OK, let's try again. If you think doctors don't give people what they want, pretty much regardless of whether or not it might be the ideal best thing for them, then explain direct-to-consumer prescription drug ads. If I am convinced that a procedure is more likely to cause harm than benefit to a patient, sorry, but I will refuse to order it. No healthy 30 or 35 or 40 year old woman with normal risk will get a mammogram ordered by me. They can feel free to go elsewhere, but in my estimation the risks are greater than the benefits. According to what you are saying, my opinon means nothing as long as the patient wants something. And go ahead and drop the age to 20....about 1 out of 1800 20 year-old women will get breast cancer within ten years. Do you want to screen them all with mammograms? If not, then what age do you want to set? Aren't you sentencing those few women to death? Of course you're not, because lots of breast cancer gets diagnosed in ways other than mammograms.

    With regard to the MRI, you'll just have to take it from me....there are no injuries that could be confused with a simple sprain that will benefit from early diagnosis that could not be determined by simple follow-up. Do you really think every sprained knee needs an MRI? No wonder we waste money on health care. And yes....there actually were doctors who owned MRI machines and they have been tempted to agree with your request. Only through careful restrictions on these things have we been able to get a handle on some of these costs.

    It's time to be realistic. In fact, it was time about twenty years ago. There is, somewhere, a limit to the amount that can be spent on health care. You can deny it if you want, but it exists. And as long as it exists, that means we will have to make some decisions as a society as to what we will pay for. I'm pretty sure your employer feels that way, and won't pay for liver or heart transplants in people they feel are not likely to benefit. They understand that costs need to be controlled. They determine their "pre-screen requirements", right? Why don't you? Why can't you understand that limiting expenditures to treatments that actually work is the right way to spend your tax dollars....or your insurance premium, because that's what's paying for it. You would rather let anyone order anything because they want it? Like I said, you call it rationing. I call it effective use of resources so that the patient can benefit...and so can many others.

    BTW, not that I think insurance companies are the best way to save money, with their profit motive and overhead...but even they realize that there is a limit. Doesn't appear you do.
  14. #14  
    Quote Originally Posted by davidra View Post
    It is worth noting, maybe several times, that the ACP has nothing to do with the government but is an organization of internal medicine practitioners. ACP link



    A great example is doing routine mammograms on every woman between the ages of 40 and 49....since all the evidence published suggests there is no survival benefit to doing that when compared to the harm/risks involved.

    To re-emphasize: This is NOT the government. It is a group of practicing doctors who want to provide the most cost-effective and highest quality care to their patients.
    This is also why people without health insurance don't die at noticeably higher rates when accounting for all factors.
  15.    #15  
    Quote Originally Posted by NathanS View Post
    This is also why people without health insurance don't die at noticeably higher rates when accounting for all factors.

    Please. Stop using talking points. Just because some people have problems with the Harvard methodology, that does not mean that the study was wrong. It's only "wrong" because right wingers don't like the results...not because they even begin to understand the methodology. If you do, of course, please enlighten us with the issues of confounding variables and problematic assumptions in an article published in the New England Journal of Medicine. Surely you know more about this than they do. After all, you are an engineering student, right? Clinical research design is certainly something you know well.
  16. #16  
    lies damn lies and statistics

    but I still support the null hypothesis.

    arbor day is coming go plant a decision tree, you can use that rag NEJM or JAMA as compost.

    this thread should be about baseball, it's less stressful.
  17.    #17  
    Quote Originally Posted by windzilla View Post
    lies damn lies and statistics

    but I still support the null hypothesis.

    arbor day is coming go plant a decision tree, you can use that rag NEJM or JAMA as compost.

    this thread should be about baseball, it's less stressful.
    The null hypothesis works just fine as long as you're healthy.

    "Less stressful"? If you mean horrifyingly boring, you're right....
  18. #18  
    Quote Originally Posted by davidra View Post
    Please. Stop using talking points. Just because some people have problems with the Harvard methodology, that does not mean that the study was wrong. It's only "wrong" because right wingers don't like the results...not because they even begin to understand the methodology. If you do, of course, please enlighten us with the issues of confounding variables and problematic assumptions in an article published in the New England Journal of Medicine. Surely you know more about this than they do. After all, you are an engineering student, right? Clinical research design is certainly something you know well.
    If by "right wingers" you mean liberal left wing health economist at UC San Diego, that actually have the cahones to do a study and stand by the result rather than design for a certain outcome...

    The most notable difference between the Institute of Medicine's data — which were drawn from the CDC's National Health and Nutrition Examination Survey as well as the Census Bureau's Current Population Survey — is that Kronick adjusted it for a number of demographic and health factors, such as status as a smoker and body mass index. When he did that, "the risk of subsequent mortality is no different for uninsured respondents than for those covered by employer-sponsored group insurance." In other words, once you compare death rates in an apples-to-apples fashion — comparing insured smokers to uninsured smokers, for instance — the likelihood of dying evens out. This, in turn, would mean that IOM's estimate of 18,000 deaths would drop essentially to zero.

    In his paper, Kronick acknowledges that this is a "counterintuitive" result, possibly resulting from the safety net of public hospitals and community clinics providing "'good enough' access to care for the uninsured to keep their mortality rate similar to that of the insured."

    Either way, he writes, "there would not be much change in the number of deaths in the United States as a result of universal coverage, although the difficulties of inferring causality from observational analyses temper the strength of this conclusion."

    We ran Kronick's paper by a number of health care policy experts to see whether they thought it undercut the Institute of Medicine's death estimate. Everyone agreed that both Kronick personally and the journal that published him are credible. Because the significance of his finding could also have political consequences — on June 24, for instance, John Goodman, president of the conservative National Center for Policy Analysis, testified to the House Energy and Commerce Subcommittee on Health that we "do not know how much morbidity and mortality is attributable to lack of health insurance" — we also wanted to determine whether there may be any ideological bias at work. But we found no evidence of it.

    In fact, far from having ties to the conservative movement, Kronick served as a senior health care policy adviser in the Clinton administration, where, according to his biography, he contributed to the development of the Clinton health care reform proposal. Kronick's articles have appeared in the New England Journal of Medicine and the Journal of the American Medical Association , and his work has at times been funded by the Commonwealth Fund, whose mission is "to promote a high-performing health care system" that aids "society's most vulnerable," including "the uninsured."

    Kronick even told PolitiFact that his finding was "not the answer I wanted" and, as a result, he agonized over whether to publish it or not. He said he's "grateful" that it has so far been unnoticed in the increasingly hostile debate over health care. "I don't have a whole lot of friends, and will probably lose a few over this," he told us. "And I might make some friends I didn't want."
    Last edited by NathanS; 04/27/2010 at 09:05 AM.
  19. #19  
    Quote Originally Posted by davidra View Post
    Truly amazing. OK, let's try again. If you think doctors don't give people what they want, pretty much regardless of whether or not it might be the ideal best thing for them, then explain direct-to-consumer prescription drug ads. If I am convinced that a procedure is more likely to cause harm than benefit to a patient, sorry, but I will refuse to order it. No healthy 30 or 35 or 40 year old woman with normal risk will get a mammogram ordered by me. They can feel free to go elsewhere, but in my estimation the risks are greater than the benefits. According to what you are saying, my opinon means nothing as long as the patient wants something. And go ahead and drop the age to 20....about 1 out of 1800 20 year-old women will get breast cancer within ten years. Do you want to screen them all with mammograms? If not, then what age do you want to set? Aren't you sentencing those few women to death? Of course you're not, because lots of breast cancer gets diagnosed in ways other than mammograms.

    With regard to the MRI, you'll just have to take it from me....there are no injuries that could be confused with a simple sprain that will benefit from early diagnosis that could not be determined by simple follow-up. Do you really think every sprained knee needs an MRI? No wonder we waste money on health care. And yes....there actually were doctors who owned MRI machines and they have been tempted to agree with your request. Only through careful restrictions on these things have we been able to get a handle on some of these costs.

    It's time to be realistic. In fact, it was time about twenty years ago. There is, somewhere, a limit to the amount that can be spent on health care. You can deny it if you want, but it exists. And as long as it exists, that means we will have to make some decisions as a society as to what we will pay for. I'm pretty sure your employer feels that way, and won't pay for liver or heart transplants in people they feel are not likely to benefit. They understand that costs need to be controlled. They determine their "pre-screen requirements", right? Why don't you? Why can't you understand that limiting expenditures to treatments that actually work is the right way to spend your tax dollars....or your insurance premium, because that's what's paying for it. You would rather let anyone order anything because they want it? Like I said, you call it rationing. I call it effective use of resources so that the patient can benefit...and so can many others.

    BTW, not that I think insurance companies are the best way to save money, with their profit motive and overhead...but even they realize that there is a limit. Doesn't appear you do.
    What did they tell you the first day in Med school? Half of what you learn here will be wrong or useless in 20 years. Your jobs is to figure out which half.
  20.    #20  
    Quote Originally Posted by NathanS View Post
    What did they tell you the first day in Med school? Half of what you learn here will be wrong or useless in 20 years. Your jobs is to figure out which half.
    Sorry. You don't have it quite right. The future is not my concern. My specific job is to teach medical students how to determine what evidence is the best available evidence right now so they can apply it to their patient decisions today. And I've been doing that for over 30 years. But thanks for your assignment.
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