Pro & Con: Which Side Are You On?

We wanted to end 2005 with a bang, and what better way to do that, we figured, than to publish a Cover Story that addresses some of the most important, controversial, and hotly debated issues confronting healthcare professionals today? The list of potential topics was practically endless: human embryonic stem cell research, pay-for-performance, medical marijuana, conscience clauses, etc etc.

In the end, we narrowed the list down to the four subjects you find here: national health insurance, pharma gifts and samples, EMRs, and tort reform. Then we solicited experts and organizations directly involved in each issue, asking them for succinct editorials outlining their positions, either for or against. We think you will find much to consider and debate in the next few pages.

WHICH SIDE ARE YOU ON?

We know you have an opinion on at least one of these topics. So don’t be shy: e-mail us at tkunkler@mdnetguide.com and vent, bloviate, and/or otherwise wax philosophical.

PRO

Johnathon S. Ross, MD, MPH, is Past President of Physicians for a National Health Program

Scott Lassman is the Assistant General Counsel for the Pharmaceutical Research and Manufacturers of America, where he is responsible for FDA regulatory and compliance issues.

N.S. Damle, MD, FACP, is a board-certified Internist and Fellow of the American College of Physicians who practices in Wakefield, RI. His practice, South County Internal Medicine, uses A4 Healthmatics. He is on the Board of the Rhode Island Quality Institute.

Sherman Joyce is President of the American Tort Reform Association (ATRA ), a national coalition of more than 300 non-profits, professional societies, trade associations, and

corporations working through in-state coalitions to bring fairness and efficiency to the tort system.

CON

Devon M. Herrick is senior fellow at the National Center for Policy Analysis and co-author of the book Lives at Risk: Single-Payer National Health Insurance Around the World.

Bob Goodman, MD, practices in the Division of General Medicine at Columbia University Medical Center and founded No Free Lunch in 1999.

Jonathan Bertman, MD, FAAFP, is a board-certified Family Physician and a fellow of the American Academy of Family Practice. He is Clinical Assistant Professor of Family Medicine at Brown University, and the founder and president of Amazing Charts.

Laurie Beacham is the Communications Director for the Center for Justice & Democracy (CJD), a New York-based group that works to protect and educate about the civil justice system.

National Health Insurance

PRO

A National Health Insurance Plan Is the Right Solution

Johnathon Ross, MD, MPH, Past President, Physicians for a National Health Program

America’s doctors and patients need single-payer national health insurance. Doctors would get paid for every patient, see malpractice and administrative costs drop, and maintain continuity of patient care with less non-compliance; outcomes and quality would also improve. For patients, soaring health insurance premiums are the norm, and the number of uninsured Americans now exceeds 45 million, 75% of whom are working people and their kids. Managed care, with its restrictions and market competition, failed to cure rising costs and created hassles for doctors and patients. Those same self-interested insurers who brought us HMOs insist that financially squeezing patients will cure the cost crisis. Again, market forces, in the guise of Health Savings Accounts (HSA), are offered as the solution. In reality, HSAs are just another way that employers shift the cost burden onto employees, whose co-payments and deductibles soar while their coverage sinks.

Unfortunately, there will never be an effective market for healthcare services. Why? The consumer’s not sovereign; the doctor, not the patient, orders the care. There’s no easy exit from the market for patients. When critically (and expensively) ill, you buy or die. The most expensive healthcare is not necessarily the most desired. There’s often inadequate information to make wise purchasing decisions. The market for medical services fails these tests of an effective market and will fail again in the guise of HSAs. National health insurance would replace private premiums with payroll taxes, funds that, when added to current public spending, would create a single insurance pool adequate to cover all Americans. A tax-based public system is simple and efficient. In multi-payer systems, however, complexity yields high administrative costs. Each insurer, hospital, and doctor must keep track of a myriad of contracts, discount arrangements, benefit packages, formularies, limited referral networks, and insurance regulations designed to reduce utilization. HSAs leave this insurance and billing bureaucracy in place and add the complexity of tracking 290 million individual savings accounts. Multiple studies confirm that the administrative simplicity of a single universal insurance pool would yield billions in savings and allow comprehensive coverage for all at current levels of spending.

America needs affordable universal health insurance. We can build it with administrative savings and public accountability but not with market solutions designed to profit the insurance industry. Single-payer national health insurance would save lives and save money.

CON

The Myth of National Health Insurance

Devon M. Herrick, Senior Fellow, National Center for Policy Analysis

The failure of national health insurance is among the great secrets of modern medicine. Not only do ordinary citizens lack an understanding of the defects of national health insurance, often they have an idealized view of socialized medicine. Virtually every country with national health insurance has proclaimed healthcare to be a basic human right. Yet far from guaranteeing that right, national single-payer systems routinely impose healthcare rationing that delays or denies needed care. Nearly one million patients in England are waiting to be admitted to hospitals at any one time, and the number of Canadians waiting for treatment of all types is roughly 875,000. Waiting patients are often in pain and risking their lives. One investigation found that delays in colon cancer are so long in Britain that 20% of the cases considered curable at time of diagnosis become incurable by the time of treatment. Another study found that 121 patients in Ontario, Canada, were permanently removed from the waiting list for coronary bypass surgery because they had become so sick that they could no longer be expected to survive surgery.

One way countries with national health insurance save money is by reducing access to expensive medical procedures. For example, the use of coronary bypass surgery in the United States is slightly more than three times as high per capita as in Canada and almost five times as high as in Britain. The use of coronary angioplasty to clear blocked arteries in the United States is almost five times as high per capita as in Canada and almost eight times as high as in Britain. The use of renal dialysis for kidney failure in the United States is nearly double the rate in Canada and almost three times that of Britain. Compared to the United States, patients in other countries also have difficulty obtaining access to advanced diagnostic equipment. Britain has about one-half as many CT scanners per capita as the United States and only one-third as many MRI scanners. The United States has two-thirds more CT scanners per capita as Canada and three times as many MRI units.

National healthcare systems have failed not because of minor glitches or easily correctable problems. Rather, the critical problems flow inexorably from the fact that they are government-run and mostly financed with taxes. The reality is that over the past decade, almost every developed country with a national healthcare system has introduced market-oriented reforms, often looking to the United States for guidance.

Pharma Gifts and Samples

PROSales Representatives and Samples Are an Important Part of Medicine

Scott Lassman, Assistant General Counsel for PhRMA

Free samples of prescription medicines accomplish two very constructive goals: They provide doctors an opportunity to determine whether a particular drug is right for a particular patient, with no obligation to continue using the medicine after the sample is gone. This can be especially useful when there is more than one medicine available in a therapeutic class. The second goal is accomplished when samples are given free to uninsured and low-income Americans who have difficulty affording medications. The chance for many patients to receive free samples is especially important at a time when nearly 45 million Americans are uninsured.

Free samples are provided to physicians by technically trained sales representatives, some of whom are nurses and pharmacists. They are well prepared to explain to physicians how medicines work, when to use them, and what potential side effects may be experienced by patients taking the medication. Sales representatives are a key source of information for doctors, though by no means are they the only source. PhRMA encourages doctors to review medical literature and journals and to get data from other sources, including medical meetings where scientific breakthroughs and discoveries are presented and discussed. But it should be recognized that America’s pharmaceutical research companies have some of the best and most complete information about their drugs. After all, these are the companies that discovered and developed the medications over a 10-to-15-year period, generating tens of thousands of pages of scientific data for each product.

PhRMA’s updated marketing code limits the promotional and educational materials that sales representatives can give to physicians. The code requires that promotional materials must benefit patients and the physician’s medical practice and limits the value to $100 or less. Notepads and pens are acceptable, as are anatomic models, medical dictionaries, and stethoscopes. Golf balls, tickets to sporting events, rounds of golf, other forms of entertainment, sterling silver serving trays, and very expensive meals are not appropriate under the PhRMA marketing code guidelines.

In the end, most physicians make it a point to control how they get information from different sources; after reviewing all of the data they’ve received, they independently decide how best to treat their patients. Trained pharmaceutical sales representatives are important contributors of information, and the samples they provide are an equally important part of the practice of medicine.

CONJust Say No to Pharma Gifts and Samples

Bob Goodman, MD, Founder of No Free Lunch

Imagine that you’re a patient and are choosing between two physicians. Physician A has a waiting room filled with pharmaceutical sales reps and free lunch, branded clocks and notepads, and a sample cabinet stocked with the newest PPIs and quinolones. Physician B has only patients in her waiting room, no branded clocks, and no sample cabinet; she gets her information from a prescribing guide she has on her PDA and The Medical Letter.

Whose prescription would you have more confidence in?

If you were to ask Dr. A if he were influenced by any of these gifts, free samples, or paraphernalia, chances are he would say no (and might even take offense at your suggesting it). There are several lines of evidence that refute this, however. There is a fairly large body of observational studies in the medical literature demonstrating that physicians are influenced by promotion. In addition, there is an even larger social sciences literature showing that gifts, even very small gifts, do influence behavior. Finally, the pharmaceutical industry spends billions of dollars per year on this sort of thing; it would be surprising if they were throwing away this much money.

Like many doctors, Dr. A will say that he sees reps in order to obtain free samples for his patients, and he will likely claim that samples are “better than nothing.” While it is admittedly difficult caring for 45 million patients without health insurance, it is simply not the case that the choice boils down to one of samples versus nothing. There are, in fact, alternatives. Like generics, for example. More and more drugs are coming off patent, and though the pharma industry doesn’t advertise this, the arrival of a generic is nevertheless usually heralded by the appearance of a long-acting formulation or perhaps an enantiomer (that’s right, Zithromax and Ambien will soon be available generically). Patient assistance programs have become easier to access; there now exist several websites dedicated to assisting in their use. The Medicare prescription drug plan will also help.

There is no longer any good reason to rely on promotional sources for information on prescription medications, given the ease with which we can now avail ourselves of unbiased drug information (just ask any medical student if you are not familiar with how to do this). It is past time to throw out the samples and throw the reps and the gifts out with them.

EMR SystemsPROAre EMR/EHR Systems Worth the Price? Yes, They Are

N.S. Damle, MD, FACP, Board Member of the Rhode Island Quality Institute

EMRs are more than worth their price. Here are 10 reasons why:

10. We use our EMR to send messages between office staff and providers about patients, phone calls, prescription refills, lab results, etc. This has eliminated the “sticky note syndrome” and the need for staff to leave their work stations to hunt for paper charts.

9. Our EMR creates medication and diagnoses lists, with easily visible allergy and drug interaction alerts, and can also track prescription refill patterns for under- and overuse by patients.

8. We can electronically prescribe to local pharmacies and automatically create a new or refill prescription within the patient chart for future tracking purposes.

7. The more complete documentation of the office visit provided by EMR systems saves valuable time for providers and staff.

6. EMRs create a more accurate, complete, and legible medical record, which improves the quality of care and attenuates risk.

5. EMRs track completed tests and issue reminders to order future tests. Our EMR compiles lab data directly into the patient chart for provider review.

4. EMRs can create disease registries, track lab data over time for effectiveness of therapy, and capture and store data in a form that is easily retrievable for clinical studies.

3. EMRs can enable interoperability between providers in all practice settings, creating truly seamless and paperless communication, limiting duplication of tests and services, and decreasing healthcare costs.

2. The CMS and other organizations have launched multiple Pay-for-Performance (PFP) pilot programs and Congress will soon pass bills incorporating PFP in any physician reimbursement updates. EMRs can effectively collect and track the data essential to participating in these programs.

1. Our EMR has saved and will continue to save money for our practice. We have saved on labor and supplies; limited our staff; and increased provider efficiency, allowing us to see more patients and deliver a higher level of care.

CON

Are EMR/EHR Systems Worth the Price? No, They’re Not

Jonathan Bertman, MD, FAAFP, President of Amazing Charts

As a family physician that uses an EHR daily, and as the founder and president of an EHR company, you’d think I’d be taking the other side here. Unfortunately, the vast majority of medical software available to us today is so ludicrously overpriced and difficult to use that the simple answer is “No, EHRs are not worth the price.” The true price of an EHR is actually a combination of costs. It is the dollar price for the software and support, the price for the hardware needed to run the program, and the cost of retraining your office staff to use it. Most of the EHR products available today dramatically fail in all three of these aspects.

First, and most obviously, is the unconscionable price tag of these systems. I mean, really—thousands to tens of thousands of dollars for something that simply writes and reads to a database? How is it that some doctors (not me) can buy a Porsche for less than the price of an EHR? When an EHR vendor won’t commit to a firm price, but instead wants to set up a demo first and negotiate pricing like a car salesman, walk the other way. Fast.

Hardware cost is the next issue. Nowadays, any off-the-shelf computer has enough power and memory to run the Space Shuttle, and wireless routers have a simple one-button setup. So why do EHR companies still require you to pay them for expensive servers and workstations that have to be connected via complex networks? Probably so they can charge you month after month for the support you’ll need to make it all work. And this doesn’t include the money you’ll spend on the disheveled IT consultant whose personality quirks you’ll be forced to tolerate each time your server mysteriously stops working and the EHR company says it’s not a problem on its end.

Finally there is the cost of actually implementing the system in your practice. You’ve spent years training to be a physician and learning how to document an encounter. It is truly astounding that EHR companies insist you now need to be re-educated to document the way their programmers believe doctors should (ie, clicking off box after box like you’re doing inventory at Wal-Mart). Even worse, they want you and your staff to spend many precious hours re-training, all while charging you hundreds of dollars per hour.

So, no, most EHRs are not worth their steep cost and difficult implementation despite the many positive features they promise to eventually provide us.

Caps on Non-Economic Damages

PROThe Case for Caps

Sherman Joyce, President, American Tort Reform Association

Adverse litigation environments in many states and large jury awards are forcing doctors to give up specialty practices, leave the profession altogether, or relocate to other states. The cost of litigation has resulted in often unaffordable medical liability premiums, causing physicians to flee to states with fairer civil justice systems and leaving many Americans without access to healthcare. The American Medical Association has identified only a handful of states that are not currently demonstrating an access-to-healthcare crisis or showing signs of crisis.

By enacting meaningful medical liability reforms, which include limits on non-economic damages, states can improve their litigation environments and prevent the continuous exodus of physicians. States that have enacted reform already have seen results in lower medical liability insurance premiums, higher physician retention rates, and the introduction of new insurers into the state.

California was one of the first states to address its medical liability crisis. In the early 1970s, liability premiums in the state soared more than 300%, causing many physicians to close the doors to their practices. In 1975, California enacted the Medical Injury Compensation Reform Act (MICRA), a comprehensive medical liability statute that includes, among other provisions, a limit of $250,000 on non-economic damages. As a result, California has had stable medical liability premiums and its citizens have access to healthcare. Similar improvements in accessible healthcare have been seen in both Texas and Mississippi. As a result of comprehensive civil justice reform legislation passed in Texas in 2003, the five largest state insurers cut rates, which will save doctors nearly $50 million. These rate reductions have lead to higher physician recruitment and retention rates in the state. Mississippi has followed a similar path since passing medical liability reform measures in a 2004 special session. Since the legislation was enacted, the Medical Assurance Company of Mississippi (MACM), which provides medical malpractice insurance to roughly 70% of doctors in the state, announced a 5% decrease in premiums for 2006. Prior to 2003, rates rose by as much as 20%.

While state-level remedies have proven successful in Califor-nia, Texas, and Mississippi, access to healthcare still remains a national crisis. In addition to supporting medical liability reform measures at the state level, the American Tort Reform Association is continuing to urge Congress to support a federal solution to this national problem.

CONThe Case Against Caps

Laurie Beacham, Communications Director, Center for Justice & Democracy

Each year, up to 98,000 people die from medical errors in hospitals alone. Hundreds of thousands more are injured, many in catastrophic and life-altering ways. While most doctors are devoted and competent professionals, there are many reasons a doctor might not meet an appropriate standard of care—some a result of being human and thus making inevitable mistakes in judgment, and some more egregious. While medical errors do not take away from doctors’ tremendous achievements or the respect most of them deserve, innocent patients whose lives are destroyed by medical negligence deserve to be adequately compensated. Capping non-economic compensation absolutely prevents that from happening.

Non-economic damages cover very real injuries such as brain damage, loss of limb, loss of child-bearing ability, and blindness. In addition to being direct compensation to patients for their tremendous losses, it pays for important quality-of-life improvements like hiring a reader for a blind person or acquiring a wheelchair-accessible van—things that can make all the difference in the daily lives of catastrophically injured people.

If a jury decides that non-economic compensation exceeds a “cap” amount, it is because the injury is extremely catastrophic. Thus, caps by definition most severely harm the most seriously injured. Caps also discriminate against groups like stay-at-home moms, the elderly, and children, whose “economic” compensation like “lost income” due to the injury might be lower. In essence, economic compensation alone puts a higher value on the lives of people with larger incomes.

Finally, it is true that some doctors have suffered exorbitant and unfair insurance rates. But caps, contrary to their stated purpose, do not and will not lower doctors’ insurance premiums. Study after study has shown that insurers set their rates based on regular economic investment cycles, not lawsuits. That is why we’ve seen premiums go up during times when malpractice payouts went down. It is a shame that many physicians have become advocates for caps, despite evidence that they are being overcharged for insurance and that caps won’t help, and that caps harm the patients they work so hard to care for. Malpractice problems will only be solved by reducing medical errors, increasing openness and discipline when they occur, and regulating an out-of-control insurance industry.