WSJ on Oregon Health Plan

The Wall Street Journal ran an op-ed this week critical of Oregon's Health Evidence Review Commission (HERC).

Some parts of it were misleading and some outright false*, but on a fundamental level the concern it expresses is correct. To the extent we turn over health insurance to government we have to live with what government gives us.

What government gives us isn't arbitrary, it's a product of a public process which because we're a democracy is ours to control. But it's for all of us to control, and what we collectively decide may not coincide with what some of us individually might prefer. That's the case with education, the law, and everything else achieved through a political process. Health care is no exception.

If that sounds scary, chew on the alternative. How effectively could we act on our preferences in the pre-ACA system?

 *Factual issues:

WSJ:  On Thursday a state board could change Oregon's Medicaid program to deny costly care to poor patients who need it most...    

 That's why HERC, for example, proposed in May that Medicaid should not cover "treatment with intent to prolong survival" for cancer patients who likely have fewer than two years left to live.

Reality:  The current guideline, adopted in 2009, restricts coverage of certain treatments for cancer patients expected to live 24 months or less.  The policy WSJ claims was proposed in May was four years old, and was preceded by even tighter restrictions.  Whatever changes HERC adopts, these kinds of coverage restrictions aren't new.

As for "costly care to poor patients who need it most," HERC is considering changing the guideline so that restrictions aren't based on expected life but instead on clinical circumstances (such as multi-system organ failure).  Such restrictions are sought precisely because those treatments are unlikely to help anyone in those circumstances.  The guideline isn't about denying care to patients who need it most, it's about avoiding care that isn't needed.  Ignoring the probability of benefit as the WSJ does is like claiming buying a lottery ticket is the same thing as getting rich.

Republicans and ineffective medicine: The saga continues

The love affair between Republicans and ineffective medicine grows ever more torrid.  Last week it was seeking to undermine the US Preventative Services Task Force, this week it's eliminating health services research.

These attacks on effectiveness research are bizarre.  Republicans claim to support market solutions to health care, but one of the biggest obstacles to that is that people have no idea what they are buying.  Are they buying a Cadillac treatment that delivers 100% satisfaction with no side effects or a 1979 Pinto that will blow up in their face?  When people can't tell the difference between shit and shinola there is no market and you can't have market solutions.   If Republicans are in any way serious about markets they should be advocating for more effectiveness research, not less.

So what explains the attraction?  Why do Republicans seek to protect treatment that doesn't work, like widespread PSA screening?  It's almost like they're afraid of the paradigm of using evidence to guide decisions.  Probably because in the real world so much evidence goes against them...

Why Evidence Based Medicine is hard

Grrr…  I see the Lund Report carried a press release from a device manufacturer lamenting Medicare's decision to drop coverage of their product for treating chronic lower back pain.  In a different universe that article would have been written by a third party without a direct financial interest and it would have been called, "Clinical studies show that TENS units offer no benefit in treating chronic lower back pain, Medicare to stop wasting tax payer money on them."  But that would be a universe in which health care wasn't eating the economy, not ours.  Why did Lund Report run this?  I'll speculate:

• It was there, and free.  The manufacturer had a financial interest in getting its message out that was not matched by any organization on the other side of the decision.  Nothing from EBM promoters, nothing from those supposedly concerned with Medicare solvency, nothing at all.

•  There is a community with a strong interest in seeing coverage continued:  current and prospective patients.  Which narrative would those people rather see:  That what they've been doing is a waste of time and money, or that government is corrupt and denying them what is rightfully theirs?  Take a guess.

Whatever the reasons, thinking about why this article was run sheds light on why the public has a hard time accepting evidence based medicine.  And no, it has nothing to do with government vs. private insurance.

ps yes, this is another example of Republicans defending ineffective medicine.