Tuesday, January 30, 2007

It's Efficacy( Does it Work?) -Not Quality That Comes First!- Says Dr. Nortin Hadler

Last Monday, Jan 22, Dr. Nortin Hadler author of probably the most important book on U.S. Health Care The Last Well Person: How to Stay Well Despite the Health-care(2005)System since Ivan Illich's Medical Nemesis written over 30 years ago(1976),wrote a groundbreaking piece for ABC News.

Now Dr Hadler is writing for ABC News and I urge you to track his latest thinking periodically on ABC NEWS

He gave me permission to reprint the essay below from last Monday. It is worth your reading.(I have bolded some statements that especially resonate with me)

"Curing Health Care Insurance-Examining the Insurance Mess - and Its Unspeakable Remedy"

OPINION By NORTIN HADLER, M.D. ABC NEWS

Jan. 22, 2007-None of us needs to be told. The health care delivery system in America is indefensible. About $2 trillion fuels the system, some 16 percent of our national productivity. If we were all covered, that's more than $6,500 per person.

Despite such a fortune, about 40 percent of us can't afford the care we are told we need, either because we are inadequately insured or out-of-pocket payments would bankrupt us.

Medical bills broke the back of more than 40 percent of us who have declared bankruptcy. Even those who feel adequately insured are bedeviled by difficulties in getting care; those inadequately insured are tormented by them.

Despite outcries, this sorry state continues to deteriorate. Why?

Clearly, the cause is not a lack of money. Every other resource-advantaged country indemnifies its entire population with less than half of what we spend, with better national health statistics to show for it.

The problem must reside in the way the money is spent.

Is the "Best" Medicine the Most Effective Medicine?

The guiding principle of all health care reform in America is the belief that American medicine is the "best" in the world.

Reform would tackle misdistribution and the inconsistencies in the quality of care. Once these are overcome, all of us will be afforded the "best" to prevent us from getting sick, and the best to heal us when prevention fails.

The savings that would result from a decrease in the national burden of illness would be enough to provide for adequate distribution of care.

It follows that the goal of health care reform is to make certain that American medicine is performed expertly so as to provide optimal quality of care.

Serving this agenda are national committees to establish the criteria for expert care for particular diseases, national committees to collect the data on how particular states, hospitals or practice groups approach these standards, and national committees to see if it matters.

Much of this effort has taken heart disease as the target because of the volume of cases, the costliness of treating these diseases, and the consensus as to the best care. Many a program has been implemented to move practice up to these standards.

The quality movement is enjoying its day in the sun. Legislators and potentates in the hospital and health insurance industries are beating the drum. Few are questioning the basic premise of the quality movement.

Does it matter to the patient if practice meets these consensus standards? There is a crying need for such heresy.

A recent analysis of the Medicare experience (JAMA, Dec. 13, 2006) should muffle the drumbeat. The degree to which practice met the accepted standards for Medicare patients admitted for heart disease did not predict who lived and who died.

Even for the poster child of the quality movement, heart disease, something is amiss.

Focusing on Quality Alone Could Compromise Care

Why wouldn't performing up to these standards of care for heart disease, to "high performance," be advantageous to the patient?

Maybe the Medicare analysis could not detect the shortcomings in the way doctors and hospitals meet standards of care.

More likely, though, is that the standards of care are far less important than the committees that formulated them pronounce.

If what we do to you doesn't work, or doesn't work much, than it doesn't matter how well we do it. It also doesn't matter how cheaply these services are provided; if it doesn't work it's worthless at any price.

The quality movement is putting the cart before the horse. The "horse" is efficacy.

The quality movement overcame great odds to gain its current influence. Physicians and surgeons, like other professionals, are not reflexively disposed to "outsiders" questioning their competence. Even peer review is a prickly process.

I applaud the quality movement and admire many of its leaders. However, quality is not the goal. It is the process. Efficacy first, then quality, promotes effectiveness.

There is an "effectiveness movement," bloodied and bent but unbowed. It can muster far more illustrative science than the quality movement.

But the forces that thwart the demand for effectiveness are powerful, wealthy and predictable.


Most of the high-ticket items (procedures and pharmaceuticals) are minimally effective, or ineffective. Many of these are considered standards of care. Many are cash cows touted by vested interests.

Effectiveness Key to Performance

From my perspective as a clinician who has cared for patients and taught students for more than three decades, if I have to treat more than 20 patients to do something really meaningful for one, the treatment is marginal; I do not prescribe or advocate it and would have no problem if it was not covered by health insurance.

If this seems extreme, consider the fact that many new and expensive treatments available today do not meet the threshold of meaningful results for even one out of 50 patients.

Furthermore, designing trials to test whether new or old treatments meet this one in 20 level of effectiveness is not difficult, expensive or time consuming. We would no longer be marketed to prescribe and consume minimally effective treatments, or treatments that offered no important improvement over the tried and true.

If we have effectiveness at the base of our health care insurance system, adding cost-effectiveness and quality would be rational and straight forward. We could well afford such a rational health care delivery system, with most of the $2 trillion to spare. We would be more "high performance" than any other country.

And our unsung, well trained and caring physicians, nurses and allied health professionals could get back to serving patients instead of the health care delivery system.


Dr. Nortin Hadler is professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and an attending rheumatologist for University of North Carolina Hospitals

Hadler is a brilliant courageous iconoclast who is dedicated to science and is meticulous and thorough with his research homework. He may make you squirm or even possibly your blood boil but I for one take his work to the intellectual "bank"

Thanks Nortin!

Dr. Rick Lippin
"Blake"

4 Comments:

Blogger stoney13 said...

Well said! There is WAY too much profiteering in the American Health Care System! And if there was any doubt as to whether it's a "man's world" or not, most of the medical miracles on the last twenty years involve getting an erection, and growing hair on bald heads!

"Restless leg syndrome" is best treated by a bicycle! It's your body's way of telling you to get off your ass and EXERCISE!!!! It's your leg muscles ATROPHYING FROM UNDER USE!!! GET UP OFF YOUR ASS! TURN OFF THE TV AND GO OUTSIDE!!! RIDE YOUR BICYCLE!! SHOOT SOME HOOPS!! OR JUST RUN LAPS AROUND THE HOUSE!!!

All these digestive ailments are because we as Americans DON"T DRINK ENOUGH WATER!!!! Coca Cola RUINS your liver!!! QUIT DRINKING THE SHIT!!!!! Thirst is your body telling you that YOU NEED WATER!! NOT SOME CONCOCTION OF CARBONATED CHEMICALS!!!

Last year I was told by a meanstream doctor that I had acid reflux diesase, and "The Purple Pill" was prescribed. A Cherokee Herbalist told me to drink a shot of vinegar every morning and eight to ten glasses of water every day. Guess what? I HAVEN"T HAD AN ATTACK OF REFLUX SINCE!! I've still got the pupple pills, and I haven't taken one in a year!

I'm not the picture of clean living either! I smoke a pack of cigarettes a day and have for thirty years! If you took all the beer I've drunk in my life and put in one place, you could throw The Mayo Clinic in it and never hear it hit the bottom! I smoke the shit out of weed, and have played with some seriosly dangerous shit in my life, yet at fifty years of age, my blood pressure is 125 over 80, and I have the lungs of an eighteen year old! Why? Except for a brief stint in the military, I have lived most of my life in the mountains of North Carolina where Big Bisiness' toxins are spewed into the environment in smaller quantities. The water from my well doesn't have chlorine or flouride in it, and the first thing my foot hits after walking out the door isn't concrete!

The reason people are dying at an excelerated rate from heart disease, cancer, and high blood pressure isn't because we don't get enough medication! It's because every day we the people are slowly being poisoned by the air we breathe, the food we eat, and the water we drink! Don't believe me? Go to the closest Elementery School, and look at all the 8-and-9-year-old-girls with fully formed breasts!! THATS from the hormones they put in the meat! 95% of the American children tested test positive for Bovine Growth Hormone, (BGH) Guess where they're getting it!

9:07 AM  
Anonymous Anonymous said...

Hey there!
Whenever I stop by my Doctor-in-law's office, it seems that he and his entire staff are being catered and expensive lunch by some phsrmacutical rep. That's how a lot of the money is spent - bribing Doctors to go with their product! No wonder drugs are so damned expensive and Dr. Nick, who is married to my sister, agrees. IT's a racket anyway you slice it.
All the best,
Tom Degan

10:44 AM  
Blogger Blake said...

Thanks to my two favorite highly creative progressive ranters Stoney13 and Tom Degan

You both are correct. Disease mongering is in full flourish. That is why Hadler called his book "the last well person". Stan Cox did a great piece on AlterNet a while back on disease mongering.

Be Well,

Dr. Rick Lippin
"Blake"

11:50 AM  
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5:41 AM  

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