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Health Policy

Final Round: FIGHT!

March 28, 2012
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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.

Florida v. HHS, Round 2: FIGHT!

March 28, 2012
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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.

Florida v. HHS, Round 1: FIGHT!

March 26, 2012
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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.

A Request

March 26, 2012

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!

Avoidable Care Conference: the schedule is live!

March 19, 2012
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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.

Values and evidence: There's a difference.

March 12, 2012
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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.

The Sidebar: Millenium Development and the Challenges of Wartime Aid Efforts

March 2, 2012
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.

And we're back, with Health Wonk Review!

March 1, 2012
Alistair Cookie

Apologies for our extended hiatus--we've been hard at work on an extended report, and it hasn't left a lot of time for blogging lately. But we're back, and hopefully we'll be blogging more often in the coming weeks.

Now, without further ado: this week's Health Wonk Review is up! Check it out.

Many thanks to Joe Padua at Managed Care Matters for hosting!

Join us again on March 14th, for the next exciting edition of Health Wonk Review!

Don't discard shared decision-making!

February 29, 2012
Austin Frakt, health economics blogger extraordinaire at The Incidental Economist, has a post up commenting on Kenny Lin's post about shared decision-making and PSA testing. The following is an edited comment I posted on that article:
I have to disagree with Kenny on this one, despite having written an article in the NYTimes Magazine that strongly supported Kenny’s work at the US Preventive Services Task Force, which found that PSA testing does not offer a mortality benefit.
Shared decision making is not about getting the patient to do what the doctor wants him to do, which judging from Kenny’s blog he thinks it is (and his opinion about the PSA test is, understandably, “Just don’t do it!”).
Frankly, as a patient, I find myself bristling when doctors (even those who are caring and well-informed) insist that they know best about what I want to do with my body. The point of shared decision making is to help patients: a) understand that ELECTIVE decisions mean the patient has a choice; b) understand the tradeoffs involved in each of the choices; and c) come to a decision that is in keeping with their values and preferences. It doesn't remove the doctor from the decision-making process, but it's not just telling patients what to do and using research to cover it up.
What I think Kenny is saying (apologies if I'm misinterpreting!) is that PSA testing shouldn't be considered an elective test—it shouldn't be presented as an option at all. I don’t know what the right answer is there, but there is a reasonable case to be made that some men might still want it, even after understanding as much as Kenny does about how lousy the test is. And it is a lousy test — as one researcher puts it, PSA predicts whether you have prostate cancer about as well as your eye color predicts the same. But while the randomized controlled trials did not find an all-cause mortality benefit from PSA testing, there’s evidence to suggest that it might possibly reduce your chances of dying from prostate cancer, though not by much. So for a man who would rather die of ANYTHING but prostate cancer (and would even prefer to die from the treatment for it) the test might be a good choice. He values avoiding a prostate cancer death, and while early diagnosis is no guarantee that he will, he might.
So while I think getting a PSA test is a really bad idea, and I don’t think I would get one myself if I were a man, and I’m glad my husband decided to forgo the test after viewing a patient decision aid, maybe it should still be considered an elective decision.
More broadly, what do the data say about shared decision making and its effect on patient decisions? A Cochrane Collaboration systematic review of more than 80 prospective RCTs comparing patients who had access to a patient decision aid (for lots of different elective decisions) and those who got usual care (the doctor tells them about their choices) found that patients who have access to an aid are better informed about the risks and benefits involved in their choices; are more realistic about those tradeoffs; and are on average 20% less likely to choose more invasive options. (That last finding is why policy makers get all excited about shared decision making.)
When you look specifically at studies of shared decision making for PSA testing, it’s not so clear that men are less likely to choose the test. There are a couple of possible reasons. I can’t pretend to have looked at all of the studies, but from a few that I’ve seen, it’s not surprising that men opt for the test because the so-called patient decision aid that was used urged them to get tested. The other reason I think its hard to dissuade men from getting tested is we have been beating the screening drum in the US for a long time. It is an article of faith that catching cancer early is universally good. It is going to take a long time to unlearn that myth.
Conclusion: discarding all of shared decision making on the basis of PSA testing is a bad idea.

Price Transparency: Progress, Not Panacea

February 27, 2012
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Shannon Brownlee's most recent TIME Ideas op-ed is up, and it tackles one of the most-repeated ideas in health care: If we give patients a financial stake in choosing less expensive care, and provide good information about which providers are cheaper than others, we'll end up with higher-value care. (After all, it works in lots of other markets--we don't have a crisis of spiraling iPad costs and lower-than-expected outcomes.) Brownlee's piece gets to the heart of why price transparency doesn't go far enough, though:

"So why do I still have no idea which lens to choose? Because I still need more information. All I know about this lens is what the slick brochure from the manufacturer is telling me. But how safe is the more expensive lens? What are the long-term effects? Can I get a new lens put in if it goes bad? That kind of information just doesn’t exist — as it doesn’t for many medical procedures."

You can read the rest of the article here: http://ideas.time.com/2012/02/27/can-you-comparison-shop-for-surgery/#ixzz1ncfvpkNU

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