Health Policy

Yesterday, the ABIM Foundation's Choosing Wisely initiative released a list of 45 medical procedures in nine specialties that doctors shouldn't use, and that patients should know are not necessary. The procedures include a variety of treatments, screening tests, and diagnostic tests, including: MRI and CT scans for low back pain without red flags; cardiac imaging tests for patients with chest pain and low risk of complications; brain imaging for a simple headache; and curative treatment for cancer patients when there's no reason to think the treatments will work.  All of the recommendations are based on solid medical evidence that the procedures harm patients, provide no benefit, or provide extremely small benefits at very high costs.

It's remarkable that the ABIM Foundation was able to pull together panels of people in all of these specialties (allergy, asthma, and immunology, family medicine, cardiology, general internal medicine, radiology, gastroenterology, clinical oncology,  nephrology, and nuclear cardiology) who were willing to agree that these treatments and tests are not beneficial to patients. It speaks to the strength of the evidence against performing useless treatments.

Dr. Vikas Saini, a cardiologist and president of the Lown Cardiovascular Research Foundation, has more commentary over at his blog:

"The truth is, guidelines and appropriate use criteria are used sparingly in practice. Occasionally, in a tough case. But there is such a guideline explosion, you need a guideline for the guidelines.  I don’t blame practicing clinicians when they ignore them. If we are to tackle this problem seriously, what we need of our doctors needs to be baked into their (our) daily cognitive frames, habits, and attitudes."

Take a look at the whole post--it's definitely worth a read.

We'll certainly be covering this initiative as it continues--there are another eight or more specialty societies preparing lists now, for release this fall,  including hospice and palliative care, geriatrics, and hospital medicine. Be sure to check out the website for the Avoiding Avoidable Care conference, as well (avoidablecare.org)--we'll be talking about a lot of the same issues!

Obamacare had its days in the Supreme Court this week, and the justices’ decision could have sweeping consequences for the individual mandate provision in the Patient Protection and Affordable Care Act, and maybe even for the fate of the law itself.

Yet whatever the court decides, we will still be stuck with a problem that this contentious law was not likely to solve on its own: an out of control health care industry that threatens the stability of the U.S. economy and the federal government’s ability to deal with our long-term debt.

Wow. Over six hours of argument later, we're left with... well, a little over six hours of audio. Now we get to wait for the decision--only 89 days to go! (The opinion will almost certainly be issued on the last day of the term, which is scheduled for Monday, June 25th.)

We haven't had a chance to listen to today's arguments yet, so without comment: this morning, in National Federation of Independent Businesses v. Sebelius, the Court considered whether the remainder of the Affordable Care Act can stand if the Court finds the individual mandate unconstitutional. This afternoon, again in Florida v. Department of Health and Human Services, the Court heard argument about the Medicaid expansion in the law--specifically, whether it amounts to an impermissible coercion of the states by the federal government. Remember, this one is incredibly important for the federal-state balance. The Supreme Court has never struck down spending as coercive before, and it would be shocking if they did now. See Aaron Carroll's piece over at JAMA if you're interested in more.

We'll be back with more blogging soon (and probably more commentary on the arguments), but in the meantime, check out the recordings! Happy listening.

Day two of argument is posted!

Apologies for not managing to post this yesterday, but the oral argument audio from yesterday's consideration of the Miminum Coverage Provision (the individual mandate). Yesterday's Twittersphere consensus was that the argument went badly for Solicitor General Verrilli, and we have to agree--there were moments when he seemed to stumble over his arguments, and points that could have been made more clearly and forcefully. The case is far from over, though, and anything the Solicitor General missed in oral argument is surely covered in the government's briefs.

Go have a listen! Today's arguments are the last: this morning, and hour and a half on severability (whether the Court must strike down the whole law, if the individual mandate falls), and an hour this afternoon on whether the Medicaid expansion is coercive to the states. That last argument is incredibly important for the federal balance of power--Aaron Carroll has a good piece on it at the JAMA Forum blog--but it would be incredibly surprising if the Court decided to strike it down. We'll post audio this evening, when both sessions are out.

We're holding off until after the whole oral argument is finished to comment, but there's no use making you wait: the audio is posted for Day 1 of Florida v. HHS, the Supreme Court case that will(?) decide the fate of the Affordable Care Act. Today's argument was actually about the question of whether the case could be brought at all: the suit might be prevented by the 1867 Tax Anti-Injunction Act, which basically prevents lawsuits to stop collection of taxes before those taxes actually take effect. If the Court decides that the Act applies, the whole case would be thrown out, and couldn't be decided until after the mandate goes into effect in 2014--meaning we might not have a ruling on its legality until 2016.

Enjoy the audio! We'll be back tomorrow for Round 2, the main event: the oral argument over the Minimum Coverage Position, aka the individual mandate.

Hello readers,

We're working on a story about the deterioration of the doctor-patient relationship, and we're looking for your stories.If you've felt like your doctor doesn't pay attention to you, or doesn't spend enough time making sure you understand your medical needs, please send us an email! The best way to contact us is by emailing patientstales@gmail.com. We hope you'll share your story!

We've been pretty quiet here at New Health Dialogue recently, but rest assured that our blogging will resume apace in the next couple of months. We've been busy working on a few projects, and I want to share one of them with you now. You'll hear more about the others soon...

If you follow our Twitter account (you should!) or Chelsea Conaboy of the Boston Globe, you've heard about the Avoiding Avoidable Care conference that we're hosting with the Lown Cardiovascular Center next month. (Chelsea did a great writeup on the conference over at the Globe's White Coat Notes blog.)

The agenda for the conference is up! We're thrilled to have such a great set of speakers, moderators, and panelists--it's going to be a great conference. While the meeting is by invitation only, we'd love to hear your comments on the agenda--post them here, and look for more in late April when we tell you about what the meeting covered.

In her latest column at TIME Ideas, Shannon Brownlee takes on the controversy over the Obama administration's birth control rule, and links it to some of the other purportedly moral debates over the extent of health insurance coverage. The core point is that, while each person is entitled to his own opinion, we're not entitled to our own facts. In cases where the facts line up solidly against a treatment, as with some kinds of back surgery, PSA testing for prostate cancer, and other elective procedures, it makes sense to limit the extent to which taxpayers and other members of insurance pools have to subsidize care. In cases where moral beliefs are at issue, though, we have to be careful to respect differences:

...the medical issues that are now sparking debate have relatively little to do with the pure numbers or effectiveness. The controversy arises because people have different moral beliefs. In a pluralistic society, we should try to respect and even celebrate that. When it comes to decisions that are rooted in values, I don’t want anyone—be it the government, my employer, or somebody else’s religious leader—coming between me and my doctor.

As part of an ongoing effort to understand the broader impact of Broadband Technology Opportunities Program (BTOP) grants, this week the Open Technology Initiative takes a look at a collaborative community-driven project in Pittsburgh that bundles civic engagement and services with broadband adoption work.

Rosa Brooks and Charles Kenny discuss the challenges facing the US military in Afghanistan after reports of Korans being burned, the role of humanitarian aid in conflict zones, and the status of the UN’s Millennium Development Goals. Pamela Chan hosts.