The Demise of Reason (and Eating Crow)
During August, the health care debate moved from the marble edifices of Washington, DC, to the highways and byways of US life. To this point, many thoughtful people have been engaged in this discussion, and interesting ideas are being proposed from all sectors of public life. This wider public forum may not be particularly well suited to parsing the nuances and Byzantine mechanics of the US health care economy, but it certainly is more theatrical—if you have the stomach for Coliseum-style entertainment. Take, for instance, the public sacrifice of Ezekiel Emanuel, MD, and the concomitant trashing of comparative-effectiveness research. As most readers will know, Emanuel is a key health care advisor to President Obama and the brother of White House Chief of Staff Rahm Emanuel. He is special advisor for health policy to Peter Orszag, director of the Office of Management and Budget. Emanuel, an oncologist and bioethicist, is director of the Clinical Bioethics Department at the National Institutes of Health. He is a known opponent of euthanasia laws, yet he was characterized as interested in denying health care to the elderly and disabled. This is not reasonable; this is politics. I can’t help wondering where the AMA was when Emanuel was accused? Why didn’t his peers come to his defense or, better yet, join the discussion? Were they indulging in some collective schadenfreude? Many physicians possess reservations about comparative effectiveness and refer derisively to cookbook medicine. Whether it’s perceived as an insurance-company plot to deny care or a meddlesome intrusion into the physician’s right to practice the art of medicine, this avenue of research is not much embraced by physicians. That it takes an average of 17 years for a clinical advance to become the standard of care¹ is a testament to the power of the status quo. At this point, Congress is so terrified of the subject that resolutions have been passed to call the rose by another name: comparative effectiveness is now clinical effectiveness. The House also passed a resolution vowing that comparative effectiveness would not be used to deny care. Our elected officials are so frightened that they passed a resolution essentially saying they would not use research to eliminate ineffective treatments. What will be used? Tarot cards? Anyone operating under the delusion that we do not already have health care rationing should have been in Los Angeles to witness the humbling spectacle of a free clinic held at the LA Forum by the nonprofit Remote Area Medical Foundation (which has staged mobile health clinics in the rural United States, Mexico, and South America). In a county where an estimated 22% of working-age adults are uninsured, the organizers anticipated crowds, but not as large as those that they got. People came from as far away as San Diego and slept on the sidewalk. Hundreds had to be turned away each day. When a Los Angeles Times columnist asked an optometrist who has done medical relief work in Mexico and South America what differences he saw between the patients seen overseas and the ones he saw in the Forum, he said: “Here, the patients speak English.”² This is a fact: Medicare cannot continue to provide care at the current level unless we reduce costs or find new funding sources. This is likely: As more people lose their jobs, deductibles increase, employers reduce benefits, and Medicaid programs are slashed, moral outrage will induce us to extend care to more people. If we don’t employ scientific research to identify the most effective treatments and eliminate those that don’t make people healthier, then how will we reduce costs? Eating Crow In the June/July issue of Radiology Business Journal, I wrote about a company called Imaging Advantage that took over the radiology contract at a network of Toledo, Ohio, hospitals. In that column, I referred to a provision in the ACR Code of Ethics that prohibited radiology groups from entering into talks with a hospital administration before advising the hospital’s contracted radiology group. I received an email from an alert reader (a practice manager in Park Ridge, Illinois) with the ACR Code of Ethics attached. He challenged me to find the reference to such a provision in the document, and I admit that I could not. Still hoping that I would not have to eat crow, I contacted the ACR, and Thomas Hoffman, JD, ACR associate general counsel, assured me that the notice provision had appeared in the code from 1957 to 1976, but not since then. In 1976, the ACR Council voted to remove that provision and replace it with language very close to this: Prior to practicing in a hospital, a radiologist shall apply, and be accepted, as a member of the hospital staff, in accordance with medical staff bylaws and in the same manner as all other physicians. Since 1976, the council has modified this provision slightly to include interventional radiologists, nuclear-medicine physicians, and radiation oncologists. The quaint practice of notifying a contracted radiology group prior to entering into talks with a hospital administration has not been part of the code for more than 30 years. Pardon my mistake. Crow is not as good as chicken, but it is far better than a pig in a poke. PS: Please check out our new portal, http://www.imagingbiz.com. You can access all articles that have appeared in Radiology Business Journal, imagingBiz.com, RadInformatics, and Medical Imaging Review. 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