A Czar to Drive Doctor-Patient Decisions
By Robert Goldberg
Since taking office, President Obama has appointed 30-some "czars" to address all manner of problems plaguing the American polity. Now, a revision in the House's version of health reform would create a Health Choices Administration, headed by - you guessed it - a health czar.
A new Health Choices Administration commissioner would oversee a national health insurance exchange in which Americans theoretically could purchase affordable coverage. In fact, this administration and its cousin in the Senate bill - a vague panel that would define what health care quality is and what to pay for it - would have sweeping powers to collect the private health and billing records of doctors and patients; regulate what physicians do and what care patients receive; and define, right down to the kind of bedpan provided, what constitutes "affordable quality care." All in the name of choice.
Cost largely will drive the czar's decisions, though he'll likely resort to different terminology, such as "patient-centered" care. This is like confusing airplane food with home-cooked meals. Make no mistake: The goal will be to generate guidelines that save money overall, even if it costs some people greater suffering - or even their lives.
In November, government officials offered a preview of how the Health Choices Administration would operate. In a much ballyhooed decision that eventually was overturned, the U.S. Preventive Services Task Force decided that giving American women in their 40s an annual mammogram was no longer necessary. Defenders of the decision claimed the panel relied on the best science available. It actually was the best science money could save.
Breast cancer mortality had declined by 30 percent since regular mammograms became standard practice for women over the age of 40 in the 1990s.
In fact, the government panelists looked at data that was focused on cost-effectiveness. They noticed that it took 1,904 breast cancer screenings of women in their 40s to save one woman's life - but just 1,339 screenings of women in their 50s to save a life. That's almost 30 percent more efficient. They - and the study on which they relied - concluded that delaying screening could save government or society money.
But those savings would come at great cost to more than a handful of women.
One in 68 women in their 40s will develop with breast cancer in the next 10 years. More than 5,000 women under the age of 50 die from breast cancer each year.
Also, the data glossed over individual and group differences in breast cancer.
"One size doesn't fit all," said Lovell A. Jones, director of the Center for Research on Minority Health at Houston's M.D. Anderson Cancer Center. Mr. Jones said the guidelines put out recently by the U.S. Preventive Services Task Force covered a broad segment of American women based on the data available.
"Unfortunately," he said, "the data on African-Americans, Hispanics and to some extent Asian-Americans is limited. ... For them, putting off the first mammogram until 50 - as recommended by the government task force - could put their lives in danger."
Cost-based calculations like these undoubtedly would creep into every part of our health sector under the new health czar. In fact, California already has adopted restrictions slashing free mammograms for poor women in their 40s that are similar to those proposed by the federal panel.
Indeed, the goal of the reform plan is not to expand innovations but to restrict them. Time and again, the health czar in the House bill and the shadowy advisory panel in the Senate bill would determine which services and choices a doctor makes are valuable and which are not. Within two years, the new bureaucracy is supposed to come up with a list of "high-value" services for certain high-cost diseases and set a price for each service.
Within three years, the czar would be churning out more one-size-fits-all mammogram-type decisions for new technologies. Health plans and exchanges would have to meet these standards, or else the czar or some czarlike force would establish them. To come up with these new standards, the health czar would have unlimited access to private data, including personal medical records and billing information.
A shortage of doctors? The health czar would have it covered. He'd prepare standards for assuring that people with diabetes, mental illness and cancer could be cared for by physician assistants and medical technicians.
And for this, most of us will pay higher taxes and premiums, face cuts in Medicare and be forced into Medicaid. Only Congress would call this "patient choice."
Robert Goldberg is vice president of the Center for Medicine in the Public Interest.