House Republican: Health Care Panel Means Patients ‘Going To Die’

[okarol]

House Republican: Health Care Panel Means Patients ‘Going To Die’
Brian Beutler | June 23, 2011, 11:55AM
     
A House Republican says a Medicare board created by the health care law will kill people.

Reprising the "death panel" meme that cast a pall over the health care reform debate in 2009, Rep. Phil Gingrey (R-GA) charged Wednesday that the Independent Payment Advisory Board -- a panel charged with reducing growth in Medicare spending -- will cause patients to die.

"nder this IPAB we described that the Democrats put in Obamacare, where a bunch of bureaucrats decide whether you get care, such as continuing on dialysis or cancer chemotherapy, I guarantee you when you withdraw that the patient is going to die," Gingrey said. "It's rationing."

IPAB will be comprised of 15 Senate-confirmed commissioners, appointed by the President in consultation with Congressional leaders. Its recommendation will become official policy unless overturned by Congress and replaced with equivalent cost-cutting measures. Though its legislative charter forbids it from "rationing" care, it will be tasked with shedding waste inherent in Medicare's fee-for-service model.

However, it will not stop paying for dialysis or chemotherapy, as Gingrey suggested.

Though it's one of the most promising cost-control measures in the health care law, IPAB has come under fire from Republicans (and even a few Democrats). Several conservatives and Republicans have now attacked it as the "real" death panel in health care reform. And its long-term fate is uncertain.

http://tpmdc.talkingpointsmemo.com/2011/06/house-republican-health-care-law-panel-means-patiens-going-to-die.php

[BillSharp]

It's pretty frightening how some conservative lawmakers will twist the plain meaning of the health care law to satisfy their voting base. I believe in total government supplied health care for everyone.

[Hemodoc]

It's pretty frightening how some conservative lawmakers will twist the plain meaning of the health care law to satisfy their voting base. I believe in total government supplied health care for everyone.

Actually, the entire Comparative Effectiveness Research (CER) and the appointed panel outside of congressional control is not a step in the right direction.  This panel will be able to make decisions with profound effects on patients and families. Taking it outside of political control is truly a frightening step in my opinion especially when the decision factors are going to be based primarily on QALY's where quality of life is assigned a monetary value for each additional year of life while under treatment.  Dialysis patients are truly on the cusp of acceptable QALY's by many studies over the last two decades.  This panel is actually outside of "Obamacare" and even if Obamacare is eventually overturned, CER and this independent panel will likely stand.

I would hope folks would take a close look at the NICE panel in England to see how this has had a negative impact in my opinion on health care choices in the British NHS. This will erode further the doctor patient relationship and decisions made on that level.  Doctors hands will be tied with no options if CER deems any treatment options too costly for any expected benefits.  We already have a recent FDA decision on an expensive but effective medicine for breast cancer:

SILVER SPRING, Md., June 24, 2011 /PRNewswire/ -- Breast cancer patients and their families will rally together on Tuesday, June 28, at 7:00 am outside of the Federal Drug Administration (FDA).  At issue will be the FDA's final hearing to remove the anti-cancer drug Avastin from the approved medication list for treatment of late stage breast cancer, despite the FDA approving it in 2008 for use to treat breast cancer.

http://www.prnewswire.com/news-releases/breast-cancer-patients-and-families-stand-up-to-fda-124482338.html

If folks believe some independent board with complete authority will make better health care decisions than you and your doctors, simply do nothing and you will no longer have the role of sole decision maker in your health care choices.  Otherwise, I would suggest folks strongly resist this intrusion into the doctor patient relationship.

Several years ago, the British NHS came looking at Kaiser Permanente's ability to provide better care for the same cost per patient as the NHS.  Kaiser has no rationing as is found in the NHS.  If the NHS itself looks for an independent, private organization to improve their health system, why are we embracing the NHS for our answers to the health care equation.  Perhaps we should instead look upon effective systems here in the US just as the NHS did several years ago when they tried to model the NHS on Kaiser's successes. Or we can simply place all of our trust in big government to care for all of our needs and hope for the best. Shall we in such a situation have the best at that point?  According to the NHS, we may be turning our backs on private systems that work better than the NHS itself.

http://www.bmj.com/content/327/7426/1241.extract

[greg10]

..
Several years ago, the British NHS came looking at Kaiser Permanente's ability to provide better care for the same cost per patient as the NHS.  Kaiser has no rationing as is found in the NHS.  If the NHS itself looks for an independent, private organization to improve their health system, why are we embracing the NHS for our answers to the health care equation. ..
http://www.bmj.com/content/327/7426/1241.extract

Hemodoc, I always respect your point of view and value your contribution on this subject.  From the little that I have researched on this subject, it seems to me that Kaiser has the advantage of choosing their patients while NHS doesn't.  The following is a rebuttal to the 2003 Shapiro paper which you cited above:
http://www.bmj.com/content/327/7426/1241/reply
"One of the ways Kaiser is able to have fewer hospital admissions and fewer length of stays is simply by its economically motivated criteria for hospital admission and care. If one is willing to sacrifice quality of care for economic reasons then fewer hospital admissions and length of stay would naturally be more efficient (economically). Furthermore, by delaying and withholding hospital admission the patients will suffer greater disability, and not infrequently lose their job and with that their health insurance (Kaiser). These patients will then be eligible for social security disability and Medicare. So other Medicare providers will have to pick up the pieces with a sicker patient requiring longer hospitalization and having a much poorer outcome. So Kaiser will have delivered less costly and more economically efficient care with the illusion of better outcome than Medicare and the NHS."

[noahvale]

^

[Hemodoc]

..
Several years ago, the British NHS came looking at Kaiser Permanente's ability to provide better care for the same cost per patient as the NHS.  Kaiser has no rationing as is found in the NHS.  If the NHS itself looks for an independent, private organization to improve their health system, why are we embracing the NHS for our answers to the health care equation. ..
http://www.bmj.com/content/327/7426/1241.extract

Hemodoc, I always respect your point of view and value your contribution on this subject.  From the little that I have researched on this subject, it seems to me that Kaiser has the advantage of choosing their patients while NHS doesn't.  The following is a rebuttal to the 2003 Shapiro paper which you cited above:
http://www.bmj.com/content/327/7426/1241/reply
"One of the ways Kaiser is able to have fewer hospital admissions and fewer length of stays is simply by its economically motivated criteria for hospital admission and care. If one is willing to sacrifice quality of care for economic reasons then fewer hospital admissions and length of stay would naturally be more efficient (economically). Furthermore, by delaying and withholding hospital admission the patients will suffer greater disability, and not infrequently lose their job and with that their health insurance (Kaiser). These patients will then be eligible for social security disability and Medicare. So other Medicare providers will have to pick up the pieces with a sicker patient requiring longer hospitalization and having a much poorer outcome. So Kaiser will have delivered less costly and more economically efficient care with the illusion of better outcome than Medicare and the NHS."

Dear Greg10,

Having practiced in the Kaiser system for nearly 11 years, the manner in which Kaiser saved the most money was in controlling the costs of hospitalization by owning the hospital and aggressively transferring patients when able from non-Kaiser hospitals back to the most cost effective Kaiser hospital.  Incentives in the Kaiser system is tied into selected patient outcomes, especially HEDIS measures such as mammography for example.  Another focus is preventive care.  The cost savings of Kaiser is in the integrated health care system that has it's own hospitals, its own clinics, urgent cares, ER's, specialists, radiology equipment, laboratories, pharmacies that cuts out the usual middlemen taking their own profits out of Kaiser related services. This is very much analogous to the dialysis giant Fresenius which gains huge market share through owning many of it's own suppliers such as for dialysis equipment as well as their ventures into pharmaceuticals as well.  The integrated health systems will always out perform those that must hire other companies for many of their needs.

Lastly, Kaiser is non-profit with no share holders taking profits out of the system, nor huge tax burdens because of the non-profit status.  Instead, those tax savings and profit sharing savings are rolled back into patient care.  It is certainly not a perfect system by any means, but now as a full time Kaiser patient, I appreciate my health system more than ever especially since I have been able to travel and dialyze in I believe 8 different states and 10 different dialysis units.  I am grateful to have Kaiser as my health care provider.  When I compare the excellent care, the excellent supplies to those of private for-profit companies I have also dealt with in the last 4 years, Kaiser comes out far and above any of them period.

Summing it up, as a physician, I was able to care for my patients without regard to fiscal aspect, I let others handle that aspect, I simply did what was right for each and every patient to the best of my abilities.  That was always my goal even if my own failings kept that from being a 100% adherence. Nevertheless, it was always my goal.  Now as a patient, I would never willingly give up my Kaiser for any other system I am aware of. In all aspects, it is a personal relationship between me and my doctor in our decision making. CER and the independent review board is completely counter to the personalized care I receive with the decisions made at the point of care, not by some unsupervised group of "advisors" with ultimate power over access to different health care technologies  In addition, Kaiser is able to accomplish this with better outcomes than the NHS with similar costs.

Lastly, it is not correct to state that Kaiser picks all of its patients. FIrst, it has many contracts with large companies offering group health to all comers in that company including dependents.  Secondly, Kaiser has a very large population made up of Medicare Advantage patients as well as Medicaid patients.  There is no selection in these groups, it is an all or none situation.  The number of individual policies with Kaiser is where a great deal of selection takes place, but it is a smaller part of the business package at Kaiser who is most dependent on large corporate contracts and Medicare and Medicaid patients where it is all inclusive of those folks in those programs.  The for-profit health care providers made up of many individual policy holders are much more selective when it comes to the total population that they serve than Kaiser by far.  In addition, a large expense in Southern CA Kaiser hospitals is uninsured who prefer Kaiser hospitals and ER's over the county hospitals and for-profit hospitals who aggressive turn folks away unless they are very unstable and unable at all to transfer.

I know a lot of folks criticize Kaiser, and in some cases, we deserve that criticism, but in general, Kaiser seeks to maximize positive patient outcomes and has a good degree of success in many areas.  That is why Kaiser is consistently ranked high in a large number of surveys of different health care systems.  So, not a perfect system by any means, but better than any of the civilian systems I have been involved with here in the US.

Oh, one more issue, Kaiser has developed some very sophisticated outpatient systems to minimize hospitalization such as case management and outpatient infusion centers to handle some moderately severe infections requiring IV antibiotics where the patients are taught to self administer the IV antibiotics in the comfort of their own homes.  Without these systems, many of these patients would needlessly stay much longer in hospitals where many are able to be discharge early or avoid the hospitalization completely going from ER to infusion center to home in the same day with daily follow up if needed in the infusion center with RN and physician supervision often on a daily basis, something that usually can only be accomplished in a hospital setting.  So, the quotation that you quoted doesn't tell the entire story of how Kaiser reduces hospital utilization with significant cost savings.  Some other health care systems also aggressively discharge folks from ER's and hospital beds as well, but cannot in any manner match the extensive outpatient support widely available to Kaiser patients.  I didn't read over the entire link today, so not sure if they mentioned any of those positive aspects of Kaiser which does indeed allow us to safely manage many folks in the comfort of their own homes, something that most patients prefer as well.

[Bill Peckham]

It's pretty frightening how some conservative lawmakers will twist the plain meaning of the health care law to satisfy their voting base. I believe in total government supplied health care for everyone.

I think you're exactly right.

I'm volunteering on the AHRQ DEcIDE ESRD Expert Stakeholder Advisory Group of the Johns Hopkins DEcIDE Comparative Effectiveness in ESRD Study. We're looking at CVD in people using dialysis something I know everyone who reads IHD is in favor of and would support.

It's in three parts but just to take one, it COMPARES three blood pressure medications to each other on their impact on CVD. When a BP drug is approved by the FDA, it means it does what the label says but the question remains which of the approved drugs does a better job. That isn't something I want to leave to the gut instinct of my doctor, I would rather there was comparative effectiveness research. I would rather a researcher at John Hopkins look at the data based on current use and say what the data shows. I would like a researcher from John Hopkins to be able to advises my doctor if one BP med has a clearly superior clinical outcome.

QALY never comes into the discussion. By law QALY cannot come into the discussion. The only question is which clinical outcomes are better. That's it.

The fact that our system does not systematically research treatment choices against each other is a critical flaw. That the efforts thus far to do some comparative effectiveness research are being misrepresented and distorted in ways that are silly with these fears that are preposterous is a disgrace. I just think it is completely nuts.

"a bunch of bureaucrats decide whether you get care" ... just take a minute and think this through. I don't think Rep. Gingrey should be taken seriously, except as a warning to anyone thinking of voting Republican.

[Hemodoc]

It's pretty frightening how some conservative lawmakers will twist the plain meaning of the health care law to satisfy their voting base. I believe in total government supplied health care for everyone.

I think you're exactly right.

I'm volunteering on the AHRQ DEcIDE ESRD Expert Stakeholder Advisory Group of the Johns Hopkins DEcIDE Comparative Effectiveness in ESRD Study. We're looking at CVD in people using dialysis something I know everyone who reads IHD is in favor of and would support.

It's in three parts but just to take one, it COMPARES three blood pressure medications to each other on their impact on CVD. When a BP drug is approved by the FDA, it means it does what the label says but the question remains which of the approved drugs does a better job. That isn't something I want to leave to the gut instinct of my doctor, I would rather there was comparative effectiveness research. I would rather a researcher at John Hopkins look at the data based on current use and say what the data shows. I would like a researcher from John Hopkins to be able to advises my doctor if one BP med has a clearly superior clinical outcome.

QALY never comes into the discussion. By law QALY cannot come into the discussion. The only question is which clinical outcomes are better. That's it.

The fact that our system does not systematically research treatment choices against each other is a critical flaw. That the efforts thus far to do some comparative effectiveness research are being misrepresented and distorted in ways that are silly with these fears that are preposterous is a disgrace. I just think it is completely nuts.

"a bunch of bureaucrats decide whether you get care" ... just take a minute and think this through. I don't think Rep. Gingrey should be taken seriously, except as a warning to anyone thinking of voting Republican.

Bill,

In 20 years of clinical practice, I have seen recommendations that ACE Inh, Diuretics, CCB's, ARB's, Beta Blockers were the most effective in one shape or another depending on which patient group and which clinical factors are evaluated.  Bottom line, it is debatable with all of the evidence which is the best. What really matters most is having an informed physician and an informed patient working together in an autonomous doctor-patient relationship.  What is clear is that there are risks and benefits for each individual patient that is different than other patients.  We have been doing comparative effectiveness research under different names for decades and using evidence based medicine as the standard of care for a long period of time.  I believe the decisions need to remain at the point of service for individualization of care for maximum effectiveness of outcomes.

Placing these decisions into a central advisory commission is way too remote from my own individual needs.  I much prefer the independence that Kaiser promotes with support of the doctor patient relationship than that which the NHS has with NICE setting standards of care and making clinical decisions with significant impact on individual patients.  Many examples of that if needed to look at, but after 20 years of clinical practice, the best medicine is always going to be with competent local decision makers who can individualize decisions around current circumstances.  Patients always come with their own set of co-morbidities and medication tolerances that always push the envelope of maximizing outcomes within those individual limitations.  So which medication for HTN is best in dialysis patients with CVD will simply be answered first by: it depends.  In the end, few patients match the highly selected criteria of a randomized and controlled trial and an individual risk benefit assessment must take place.  These decisions in my opinion need to remain local.

[Hemodoc]

Looks like the AMA places getting rid of the 15 member board as it's highest priority right now.

http://www.foxnews.com/politics/2011/06/25/doctors-group-seeks-repeal-medicare-cost-control-board-in-health-law/?test=latestnews

[Bill Peckham]

The Washington Post fact checks Rep Gingry here http://www.washingtonpost.com/blogs/fact-checker/post/are-medicare-patients-going-to-die-under-obamas-health-law/2011/06/23/AG3nJuhH_blog.html

I think this is a succinct summary:
The dispute really centers on a philosophical divide between the parties. Democrats would rely on independent experts (such as doctors and consumer advocates) to recommend the cuts; Republicans would rely on the insurance marketplace to control costs.

If you accept that Medicare costs have to be checked, which both parties agree, then here is your choice.

And as you consider the Republican option consider that doctors have been practicing medicine for thousands of years yet it is only in the last hundred years that medicine has been effective. For millennia doctors have given care that made the illness worse, how could that happen if the market worked in healthcare? If the market worked in healthcare blood letting would never have been widely practiced. If markets worked in healthcare no one would have ever paid for medicinal enemas to treat typhus.

The Republican plan, the Ryan plan, is a disaster for people who use dialysis. If the Ryan Medicaid cuts are allowed to proceed it will effect every dialyzor's care. That is the choice we face - huge decreases in funding for dialysis or a committee meant to "mimic the Defense Base Realignment and Closure Commission". The IPAB is a way to make politically difficult decisions- but decisions that must be made. I think the public will be much better served if experts put forward changes that make sense vs leaving it up to seniors to shop for their coverage in a "free market".

We have an example in the dialysis world of how policy can improve care and lower costs - EPO. Answer this: should you have the right to have as high an EPO induced Hgb as you and your doctor think? Specifically do you think Medicare Primary patients have the right to have a 13.5 Hgb?

I say no. I say Medicare is being prudent to follow the FDA approved label and limit treatment of anemia to a target between 10 and 12. I think Medicare was right to change the way they reimbursed EPO from per dose to instead target an anemia outcome. I think the EPO policy change is a perfect example of the sort of cost controls that will come from IPAB. The impact of reimbursement on use of EPO from 1989 through today provides a clear example of how fee for service Medicare distorts medical care, and the recent changes in reimbursement for EPO are a perfect example of how changing payment can result in fewer resources being used to achieve better outcomes.

I think the dialysis program, the ESRD program administered by Medicare, is a model of cost control that can be applied to good effect to the rest of Medicare. Is it painless? No. But given that the alternative being offered by Republicans is deep cuts in funding coupled with increases in per treatment costs ... I believe it's not even a close call as to which way the country should proceed. We have a stark choice, the status quo isn't an option, I think the way forward is clear, certainly the way forward in the best interests of dialyzors is clear.

[YLGuy]

 
I saw the Fox News post and was going to ask HD to reference a news source that was actually credible.  Then I refreshed and saw the first sentence of Bills post.  FOX is NOT a news source it is a biased political commentary. 

[MooseMom]

The "EPO" argument is compelling.  To think that dialysis providers and their associated nephs would prescribe high doses of EPO not because it was good for patients (which, we see, it was not) but, rather, because it represented a reliable and lucrative revenue stream is despicable and has nothing to do with the rights of patients and doctors working together without outside interference to create an efficient treatment plan.

[PatDowns]

I saw the Fox News post and was going to ask HD to reference a news source that was actually credible.  Then I refreshed and saw the first sentence of Bills post.  FOX is NOT a news source it is a biased political commentary.

No, YOU are the one with bias.  How about actually checking the FACTS? 

http://www.politifact.com/truth-o-meter/statements/2011/jun/20/jon-stewart/jon-stewart-says-those-who-watch-fox-news-are-most/

But then again, you probably think Politifact.org is also spouting biased commentary.

[YLGuy]

Wrong.

http://www.fair.org/index.php?page=1067

[PatDowns]

This is the best you can do?  An article written in 2001 by a left winger in a left leaning publication?  You hold FAIR in higher regard than Politifact.org? 

Wrong.

http://www.fair.org/index.php?page=1067

[YLGuy]

Look PD, this is getting off topic.  Fox is known for their non-fact reporting.  I attacked Fox and in turn you attacked me.  Get a grip. This is stupid to argue.

[PatDowns]

Look PD, this is getting off topic.  Fox is known for their non-fact reporting.  I attacked Fox and in turn you attacked me.  Get a grip. This is stupid to argue.

I didn't attack you, personally - I attacked your post.  You could not prove me wrong, so now you deflect.  Typical lefty tactic.   And, no, Fox News is not known for their non-fact reporting.  Well, not to anyone other than far lefties.

[jbeany]

*sigh*  We need a referee whistle icon.

Everyone back to their corners, please. 

No, YOU are the one with bias.

However you intended this, Patdowns, it, unfortunately, does read as a personal attack.  Tone inevitably gets lost in typed posts.  You are both welcome to debate the veracity of news sources, but please, let's not attack each other personally.

Current political facts are always going to be interpreted differently by both parties, as is the reporting of them.   It seems to me that you both have an interest in informing our less politically involved members of government actions that will affect those with ESRD.  This is an important goal.  To reach, it would be lovely if you could both agree to disagree, please, before an interesting and relevant post has to be locked because of the tone.

Thank you both for your efforts to keep us informed of both sides of the debate.

jbeany, Moderator

[YLGuy]

I saw the Fox News post and was going to ask HD to reference a news source that was actually credible.  Then I refreshed and saw the first sentence of Bills post.  FOX is NOT a news source it is a biased political commentary.

No, YOU are the one with bias.  How about actually checking the FACTS? 

http://www.politifact.com/truth-o-meter/statements/2011/jun/20/jon-stewart/jon-stewart-says-those-who-watch-fox-news-are-most/

But then again, you probably think Politifact.org is also spouting biased commentary.

This is a personal attack.  Moderators, please advise. 

[okarol]

I saw the Fox News post and was going to ask HD to reference a news source that was actually credible.  Then I refreshed and saw the first sentence of Bills post.  FOX is NOT a news source it is a biased political commentary.

No, YOU are the one with bias.  How about actually checking the FACTS? 

http://www.politifact.com/truth-o-meter/statements/2011/jun/20/jon-stewart/jon-stewart-says-those-who-watch-fox-news-are-most/

But then again, you probably think Politifact.org is also spouting biased commentary.

This is a personal attack.  Moderators, please advise. 

A moderator did respond. Thanks jbeany.

Just refrain from personal attacks and everything is fine.

okarol/admin

[Meinuk]

Current political facts are always going to be interpreted differently by both parties, as is the reporting of them.   It seems to me that you both have an interest in informing our less politically involved members of government actions that will affect those with ESRD.  This is an important goal.  To reach, it would be lovely if you could both agree to disagree, please, before an interesting and relevant post has to be locked because of the tone.

Thank you both for your efforts to keep us informed of both sides of the debate.

jbeany, Moderator

I am absolutely loving jbeany the moderator right now!!!

[MooseMom]

For what it is worth, and if you deem The Washington Post's Fact Checking column as a creditible source, Representative Gingrey's statement earned "Three Pinocchios", ie, "significant factual error".

It's really abhorrent that some politicians will just make up stuff so that they can scare their constituents into voting a certain way, especially when the objective is to create terror among the most vulnerable voters whose cancers and failing kidneys already have them in a state of panic.  Shame!

[RichardMEL]

Heavens, people making personal attacks over the accuracy of Fox News? REALLY? 

Not only is it off topic to the discussion, but it's pretty funny to me. I live on the other side of the world and I watch Fox News when I want a laugh!  And it's owned by an Australian, so I feel entitled somehow ! 

Yep, feel free to attack me personally for that - but please, do the forum a favour and make it in a PM!

thank you

RichardMEL, Moderator