Astroturf

Written by: Harold P on Jun 1, 2009 10:37 AM EDT

Jerry Avorn is a Harvard physician-health researcher who popularized the practice of "academic detailing" in doctors' offices and hospitals to counter the propaganda pitched by pharmaceutical reps. In similar spirit, Avorn recently delivered a well-deserved tongue-lashing to those waging the Astroturf campaign against comparative effectiveness research (CER) http://content.nejm.org/cgi/content/short/360/19/1927.

Avorn's article is surprisingly harsh, considering that it appears in the normally-sedate pages of the New England Journal. He notes the well-orchestrated campaign, brutishly anchored on the right by Rush Limbaugh's attacks on "porkulus," and in more seductive tones by Republican physician-politicians such as Representative Tom Price of Georgia, who warn that CER is the thin end of a wedge leading to government rationing of care.

A recent column by conservative provocateur Betsy McCaughey exemplifies the sheer phoniness of this Astroturf campaign. (If her name seems familiar, McCaughey is most famous for her dishonest, though politically damaging attacks on Hillary-care fifteen years ago.)

In a column called "Ruin your health with the Obama stimulus plan," McCaughey slams Thomas Dashle for promoting the use of CER. Her column is worth quoting at length, in part because it has been widely quoted by Limbaugh and others:

Dashle proposed an appointed body with vast powers to make the "tough" decisions elected politicians won't make.

The stimulus bill does that, and calls it the Federal Coordinating Council for Comparative Effectiveness research (190-192). The goal, Dashle's book explained, is to slow the development and use of new medications and technologies because they are driving up costs. He praises Europeans for being more willing to accept "hopeless diagnoses" and [to] "forego experimental treatments, and he chastises Americans for expecting too much from the health-care system.

Elderly hardest hit

Dashle says health-care reform "will not be pain free." Seniors should be more accepting of the conditions that come with age instead of treating them. This means the elderly will bear the brunt.

Medicare now pays for treatments deemed safe and effective. The stimulus bill will change that and apply a cost-effectiveness standard set by the federal council (464).

Like Dick Morris--who repeatedly fibbed that the Obama health plan would ration healthcare to seniors to finance care for undocumented immigrants http://www.samefacts.com — McCaughey seeks to frighten people with images of Ernest Bevin pushing grandma out on the ice flow in some nightmare image of the British National Health Service, circa 1952.

McCaughey provides a grossly misleading account of cost-effectiveness analysis and how it is actually used in other wealthy democracies. She is even less accurate in describing President Obama's policies and the recent stimulus bill. For example, she leaves out the passage of the new law that reads: "Nothing in this section shall be construed to permit [the Federal Coordinating Council] to mandate coverage, reimbursement or other policies for any public or private payer."

The idea that Democrats are itching to ration care to seniors is hard to reconcile with, well, everything we know about American politics since the New Deal. A standard Republican trope is that Democrats pander to seniors and oppose serious "entitlement reform." Witnessing the increasing costs associated with dementia and other ailments requiring long-term care, it was a Republican, HHS Secretary Michael Leavitt, who warned http://www.huffingtonpost.com/harold-pollack/governor-palin-delivers-l_b_138262.html that "Medicaid must not become an inheritance protection plan." Maybe the graying of the conservative base is leading Republicans to sing in a new key.

Current Republican proposals include much more stringent efforts to constrain and means-test Medicare expenditures. Incidentally, the Kaiser Family Foundation reports that the leading Republican proposal would also "Create a new Health Care Services Commission to establish uniform measures for reporting price and quality information." The HSC, managed by five commissioners from the private sector appointed by the President, will issue a report containing guidelines regulating the publication and dissemination of health care information and will be authorized to enforce these standards." http://www.kff.org/healthreform/upload/healthreform_sbs_full.pdf

When one cuts through the fear-mongering, there is nothing radical or especially liberal, about CER. During the campaign, the Obama and McCain camps squabbled about nearly everything: how to regulate insurers, how much to subsidize poor people, what to do about preexisting conditions, whether to cut Medicare and Medicaid, what to do about stem cells, and more. Come to think of it, though, nobody squabbled about comparative effectiveness research.

There was a good reason for this. Everyone with even basic familiarity with healthcare realizes the insanity of spending $2.4 trillion without having a much better sense of what we are actually getting for our money. Insurers, employers, and parents want to know whether that two-month inpatient adolescent psychiatry stay or that extra costly MRI will really help. We want to know whether that $20,000 lumbar procedure for vague back pain is likely to work. Doctors want to know whether their patients really need the next-generation arthritis medicine when there is a familiar generic backed up by 20 years of safety and efficacy data.

This simple point is well-known across the political spectrum. As John McCain might say with a little impolite straight talk, it's a mighty strange coincidence that the fiercest opponents of CER are medical device and drug companies and surgical subspecialists whose oxen, one suspects, deserve to be gored.

Here, for example, is the view of one scholar http://finance.senate.gov/Gail%20Wilensky.pdf:

The development of more and better information on comparative clinical effectiveness, particularly if its use were encouraged by such concepts as value-based insurance and value based reimbursement, could both improve care quality and potentially slow health care spending….

… These efforts have now been jump-started with the $1.1 billion for comparative effectiveness research provided in the Stimulus bill. As important as this provision is, it needs to be recognized as the first step in what will need to be a long-term commitment in investing in such efforts.

Noting the need to use CER to change the way care is delivered, she went on to add:

[N]ew information alone may not be enough to change physician or patient behavior. Changing incentives for clinicians and their patients, better aligning financial incentives between clinicians and institutional providers and combining information on effectiveness with cost data in setting reimbursement rates will also be important if spending is to change.

These words weren't penned by Tom Dashle or Rahm Emanuel. They were presented last week by Gail Wilensky, a top Republican health expert and a key spokesperson for the McCain presidential campaign.

I often disagree with Wilensky and with other Republican experts such as Douglas Holz-Eakin. Yet these men and women argue within a reality-based community, in which evidence actually matters, and in which political and policy debates are conducted with greater depth and integrity than Betsy McCaughey or Dick Morris can muster. I can hardly imagine more appalling partisan hackery than these two have displayed.

Postscript: Hold the presses. There is something more appalling!

Thanks to great reporting by the Washington Post http://www.washingtonpost.com/wp-srv/politics/health-care/BCBSNC_HealthplanVideo.pdf, we have draft copies of three fearmongering TV commercials commissioned by BlueCross BlueShield of North Carolina that attack proposals to offer consumers a public health care plan. These attack ads on "government-run health care" are peppered with ominous background phrases and questions: "rising premiums," "individual mandate," "preexisting conditions," "what about lines," and more.

Paul Krugman had fun with this in a nice recent column, aptly titled "Blue Double Cross." http://www.nytimes.com/2009/05/22/opinion/22krugman.html?_r=1. He notes that virtually every particular in these ads is misleading. Ironically, background investigation by the watchdog group, Media Matters http://mediamattersaction.org/factcheck/200905190001 indicates that BCBS of North Carolina has a long rap sheet itself—one that includes precisely the missteps and infractions it wrongly insinuates would arise from a public insurance plan.

Now that is chutzpah.

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