Thursday, December 20, 2007

You Can't Tell the (Health Care Policy Op-Ed) Players Without a Scorecard

With the run-up to the US presidential election starting in earnest, public discussion of health care policy issues is ramping up. As has occurred before, we hear a lot from people apparently on the right who advocate for a laissez faire approach to health care free of government involvement. Such people often tend to approve of much of what health care corporations do. We also hear a lot from those apparently on the left who favor government operation of particular segments of the health care system, particularly health insurance. They tend to be very critical of corporate health care, but to approve of much of what the government does.

These discussions often take place in the most prominent fora in the main stream media. For example, last week Dr Scott Gottlieb wrote "Stop the War on Drugs," a commentary for the Wall Street Journal. Gottlieb focused on how the US Food and Drug Administration and the Department of Justice challenge off-label marketing by pharmaceutical companies. He noted cases in which he contended that the government prosecuted companies for "educational" dissemination of information already widely available in the medical literature. Further, he implied that these attempts are part of efforts to make "off label" into "dirty words in the conventional lexicon." Gottlieb did not address cases in which companies promoted off-label use which was not supported by good evidence, e.g., the Neurontin case, and seemed to conflate marketing with education. His main point seemed to be that overly strict regulators were hindering physicians' education and hence keeping people from getting the drugs they need.

Also last week, Dr David Himmelstein and Dr Steffie Woolhandler wrote "I Am Not a Health Reform," a commentary for the New York Times. The thrust of this article was to discredit the employer mandate approaches now advocated by some presidential candidates to reform health care. They called the "mandate model" "economic nonsense." Instead, they asserted "only a single-payer system of national health care can save what we estimate is the $350 billion wasted annually on medical bureaucracy and redirect those funds to expanded coverage." Himmelstein and Woolhandler did not address any deficiencies in how our current national single-payer system, Medicare, allocates money, in particular how it follows reccommendations by the secretive, proceduralist-dominated RBRVS Update Committee (RUC) that have lead to a relentless squeeze on primary care. Their main point seemed to be that only government run health insurance will solve our current problems.

Thus, much of the debate seems to be between those who see any government involvement in health care as ill-conceived or worse, and those who see government operation of whole health care segments as the only solution. Rarely discussed are ways in which government could better regulate health care to improve health and safety, without actually running it; or ways to re-invigorate the involvement of not-for-profit organizations in health care so they actually fulfill their missions, or revitalize the health professions so they can rediscover their professional values.

Perhaps this domination of the debate by those on the extreme ends of the spectrum would lessen if the audience knew more about who was trying to sway them.

Dr Scott Gottlieb, for example, was described in the WSJ as "a practicing physician and resident fellow at the American Enterprise Institute, [who] was deputy commissioner of the FDA from 2005 to 2007." However, Dr Gottlieb has more relationships with health care corporations than were revealed by this one-sentence biography.

Just before he took that job, the Seattle Times reported, "Only a month ago, Dr. Scott Gottlieb was a Wall Street insider, promoting hot biotech stocks to investors." Also, "he also has consulted for, and written positively about, a major matchmaking firm that links doctors with Wall Street investors, the Gerson Lehrman Group in New York."A few months later, the Boston Globe reported that as FDA Deputy Commissioner, Dr Gottlieb had to recuse himself from discussions about dealing with an avian flu epidemic

because his past consulting work for [large public relations firm] Manning Selvage & Lee involved companies whose products would be used to combat a flu pandemic. Gottlieb's former clients include Roche -- manufacturer of the highly sought antiviral Tamiflu -- and Sanofi-Aventis, parent company of the nation's sole flu vaccine manufacturer.

Manning Selvage & Lee paid Gottlieb a $12,500 monthly retainer for nine months for business development projects that included eight companies. Other firms regulated by the FDA he was involved with include Inamed Corp., one of two companies seeking to return silicone gel implants to the market. He also did private consulting work for VaxGen Inc., a California firm that won a $878 million federal contract to supply 75 million doses of anthrax vaccine for the nation's protective stockpile. The $9,000 he accepted from VaxGen for consulting work between May and July prevents him from doing FDA work related to that company until August 2006.

Furthermore, Gottlieb was recently appointed to the board of directors of Molecular Insight Pharmaceuticals, a "a biopharmaceutical company specializing in the emerging field of molecular medicine." As a member of the board, Gottlieb is supposed to have "unyielding loyalty" to the company's stock-holders.

Readers of Gottlieb's opinions about health care, especially those that favor a laissez faire approach to regulating pharmaceutical companies, need to wonder the extent that these beliefs are influenced by his former and current ties to the industry.

On the other hand, Dr Himmelstein and Dr Woolhandler were identified as "professors of medicine at Harvard and co-founders of Physicians for a National Health Program." While Dr Himmelstein and Dr Woolhandler have long used the friendly Canadian example of single-payer government health insurance to buttress their arguments to the public,(1) in the past, and did so again in their latest op-ed, they previously acknowledged that their approach was frankly "Marxist," rather than Canadian.

They authored apparently pure Marxist analyses of health care in the late 1980s.(2-3) Previously, they had openly advocated for "socialized medicine."(4) They praised the operations of the communist health care system under Tito in what was then Yugoslavia.(5)

Readers of Dr Himmelstein's and Dr Woolhandler's opinions about health care, especially those that favor the government running health care insurance, need to wonder about the extent that these beliefs are influenced by their ideological ties to Marxist and communist theories that in retrospect have been discredited.

Those who opine on major health policy issues should at least reveal where they are coming from. In any case, the debate would benefit from some fresh voices not tied either to health care corporations or Marxist ideology.

References

1. Woolhandler S, Himmelstein DU. A national health program: northern light at the end of the tunnel. JAMA 1989; 262: 2136-2137.
2. Himmelstein DU, Woolhandler S. The corporate compromise: a Marxist view of health maintenance organizations and prospective payment. Ann Intern Med 1988; 109: 494-501.
3. Woolhandler S, Himmelstein DU. Ideology in medical science: class in the clinic. Soc Sci Med 1989; 28: 1205-1209.
4. Himmelstein DU, Woolhandler S. Socialized medicine: a solution to the cost crisis in the United States. Int J Health Services 1986; 16: 339-354.
5. Himmelstein DU, Lang S, Woolhandler S. The Yugoslav health system: public ownership and local control. J Public Health Policy (9) 1984; 423-431.

14 comments:

Anonymous said...

I was taken aback by a number of items in Scott Gottlib’s piece. First the size. I was always taught you should be able to make a point in the shortest space.

Secondly, pharma has no free speech rights. Free speech only applies to personal speech and not commercial speech. The simplest example would be cigarettes.

Third, the FDA is charged with regulating off label marketing of drugs.

Unless some major legal changes are being planned, everyone is acting in accordance with the current laws of the United States.

As a follow on, the Dec. 20th WSJ highlights the suit filed by Jesse Polansky against Pfizer over Lipitor marketing. With sales of $13.6B last year alone, it is the world’s biggest-selling drug. The contention is that Lipitor was marketed for those with no real need for the drug through dinners and other peer presentations.

The WSJ Health Blog has some interesting firsthand comments regarding what took place at these dinners, who were the presenters, and most importantly, who prepared the material. Basically a company Pfizer paid.

On a personal note, five years ago I was told I needed a statin, prior to any testing. When I questioned this statement the doctor responded she worked hand in hand with the drug reps and by the time I was 55 it would be a requirement to maintain my insurance.

Most recently, and 125 miles away, a 58-year-old friend with an LDL of 122 and a HDL of 50 was told he needed a statin. When he declined his doctor told him he would still be required to submit to office visits and blood draws every six months.

One really has to question this statin for all mantra and the cost associated with this drive. Pharma’s marketing machine certainly has succeeded with this product.

Steve Lucas

Anonymous said...

Steve--

Another convenient "add-on" is antidepressant for diabetics. When my husband, seeking a new endo, asked for an interim "prescription" for diabetes supplies (needles, strips), the doctor would not supply an Rx until all results from comprehensive blood work were evaluated. Nevertheless, the Dr. had no compunction about offering a couple of sample packs of Seroquel on the way out the door. Seems that diabetics MUST be depressed and needful of pharmacologic intervention. (Hubby has been diabetic for 50+ years, certainly has had ups and downs, but never felt the need for a pharma solution.)

Anonymous said...

I find it interesting that Stalinism in the Soviet Union (a form of state absolutism scarecely distinguishable with Czarist autoctracy, and with no relationship, except in lip-service, to communism...or even socialism) is held to "discredit" Marxism -- a mode of political and economic analysis still held to be respectable (or at least worthy of debate) in most countries other than ours.

George Williams said...

Excellent work Dr. Poses! So much so that I have included it in our pre-holiday Health Care Blog Roundup at the Health Care Reform Now Blog. You may view the post here:

http://healthcarereformnow.blogspot.com/2007/12/holiday-tidings-health-care-roundup.html

Anonymous said...

Anonymous,

I am not a doctor, but will say, what you and your husband experienced is wrong on so many levels.

Steve Lucas

Roy M. Poses MD said...

To the anonymous commentator who suggested that Stalin was not a communist - You hare kidding, aren't you?

revere said...

The question whether Himmelstein and Woolhandler are Marxists is kind of irrelevant I'd say, just as the fact that you may be a Chicago School Economist or whatever. The implication is that if you aren't a US mainstream economics ideologist than you have to declare your alternative as a conflict of interest? That seems kind of silly to me. They identified themselves as belonging to PNHP. This strikes me as bordering on red baiting, something I thought we'd gotten over. I'm disappointed in this since you have done so many very fine posts.

Roy M. Poses MD said...

The part of the above post discussing the Himmelstein and Woolhandler op-ed has drawn quite some comment (much off-line, but also above.)

Thus, I thought I should in particular address revere's comment, which could be unpacked into a really long discussion. Instead, but let me try an only moderately long answer first.

First, let me make it clear that Himmelstein and Woolhandler had publicly identified their Marxist stance in multiple publications. In no sense did I "out" them, or expose their private thinking, to which I am not privy, in any case.

They do seem to have kept their Marxist writings separate from their health care policy publications, which have usually been in more mainstream fora. Note also that they have written in a Marxist vein relatively recently. For example, in 2000 they wrote approvingly "the Marxist tradition has delineated a socialized biology...." (See Woolhandler S, Himmelstein D. Lost in translation. Boston Review, Feb/March, 2000.
http://bostonreview.net/BR25.1/woolhandler.html)

Marxism to my knowledge is more than merely a school of economics. For example, the Merriam-Webster definition is:
"the political, economic, and social principles and policies advocated by Marx; especially : a theory and practice of socialism including the labor theory of value, dialectical materialism, the class struggle, and dictatorship of the proletariat until the establishment of a classless society."
(See http://www.m-w.com/dictionary/Marxism)


I did not accuse Himmelstein and Woolhandler of having a conflict of interest, certainly not a traditional economic conflict of interest. But I believe that knowledge of their Marxist orientation would be as relevant to a reader of their op-ed as knowledge of Gottlieb's financial ties to the pharmaceutical and biotechnology industries would be to a reader of his op-ed.

Knowing that Gottlieb has ties to the pharmaceutical and biotechnology industries raises the question of whether he was trying to promote those industries' interests in his op-ed, not just improve health care for all. For example, decreasing regulation of "off-label" promotion might improve the profits of these industries.

Knowing that Himmelstein and Woolhandler share the Marxist viewpoint raises the question of whether they were trying to promote the whole Marxist agenda in their op-ed, not just improve health care for all. Some people might wonder if having the government take over a whole sector of the economy (health insurance) might further the "class struggle" on the way to a "dictatorship of the proletariat."

Gottlieb did identify himself with the American Enterprise Institute, generally considered to be a conservative or libertarian not-for-profit organization. But affiliation with the AEI does not imply a direct financial relationship with any drug or biotechnology company.

Himmelstein and Woolhandler identified themselves with the Physicians for a National Health Program (PNHP). This not-for-profit organization is an advocate for a government single-payer health insurance program (see http://www.pnhp.org/about/pnhp_mission_statement.php), but affiliation with the PNHP does not imply identification with or approval of Marxism.

Regarding the issue of "red baiting" - I will admit I strongly believe that Marxism-Leninism and communism have lead to a lot of human misery. The health care systems of the former Soviet Union and its former communist satellites had a particularly sorry record, despite considerable propaganda and disinformation to the contrary. Thus I believe the burden of proof on anyone still advocating "Marxism" in health care is to show why it might work better this time around.

Finally, I am glad you appreciated some of our posts. We don't expect anyone to agree with us all of the time.

Revere said...

I appreciate your response, which is to the point and clear. As you suggest this is not going to be settled in a comment thread or anywhere else, for that matter. But I think there is one serious misconstrual in your response I cannot help but observe. There are many strands in what is called Marxism that you seem to have lumped rather uncritically together: Marxism, Marxism-Leninism and communism being the three you mention, but your dictionary definition includes political as well as economic features of things lumped under the heading of Marxism in some contexts but not in others. The heart of Marxist economics is the labor theory of value and the market. The extent to which Marx's social views are related (and there were several Marxs in that sense) is a matter for endless debate, but the further categorizing all people who have espoused a view they describe as Marxist as Soviet-style communists is not only inaccurate, it is a kind of redbaiting I remember from the 50s (yes, I'm that old) but don't see as much of these days. But its descendants echo everytime we hear a Republican candidate criticize universal health care as "socialized medicine." After all, Soviet communists called themselves socialists, right?

Roy M. Poses MD said...

Re: Revere's latest comment...

There is certainly a terminology problem here.

The terminology was made rather more difficult by the communists' practice of referring to themselves as "socialists," or "progressives," when it suited them to appear more moderate.

This did make it easier for those on the right to add connotations to an attack on "socialized medicine." On the other hand, it is quite possible for someone on the right, or even in the center to disagree with government control and/or operation of an economic sector on purely economic grounds.

In addition, I know plenty of progressives and a few democratic socialists (or social democrats) who certainly do not resemble communists in the least. But I don't recall any who would refer to themselves as "Marxists."

To address the specific issue at hand, we would have to go re-read Himmelstein and Woolhandler's writing in detail to get a better sense of what they meant by "Marxism" and "Marxist." But my first reading did not suggest that they used the terms to refer to, say, just democratic socialism, liberalism, progressivism, or generally being on the left-wing of politics.

In particular, their characterization of Tito's Yugoslavia as practicing "socialism," and being "highly democratic," suggests that their approach was more like "Marxists" cloaked as "socialists," than democratic socialists unfairly labeled "Marxists." (See Himmelstein DU, Lang S, Woolhandler S. The Yugoslav health system: public ownership and local control. J Pub Health Policy (9)1984; 423-431.)

Elliott said...

No. Roy you are making a mistake. you do not have to go into some indepth analysis of their writings. You have to understand that they are academic economists. In that context, "Marxist" has a particular connotation separate from the one you are thinking about. It is a shorthand to describe a school of thought like "Austrian", "Keynesian", "Monetarist". In addition, people use these kind of descriptions to provide framework to their audience and not a straitjacket. It does not have any relationship to the dictionary definition that you are consulting. I do not think you are being malicious in making this mistake, but if you persist after it being pointed out to you then there is a problem.

Roy M. Poses MD said...

I am fascinated by the sorts of comments one aspect of this post has drawn, in contrast to the comments, or lack thereof drawn by my many other posts.

Re Elliott's comments - But Himmelstein and Woolhandler are academic physicians, not academic economists, at least by their training and faculty positions. And all the writings I cited were in medical or public health journals, save the 2000 piece in the Boston Review. They were not in economics journals, or apparently directed at economists. And all the articles except, save the Boston Review article, were about health care, not economics, although they did have economic elements. So what sense does it make to claim that Himmelstein and Woolhandler are academic economists writing using shorthand terms that other academic economists, but not physicians, would understand?

I would ask "Elliott," whoever he is, to go look at what Himmelstein and Woolhandler wrote. If after doing so he is still convinced that they were writing in an academic economic, rather than a political tradition, and can explain it to me, I will cheerfully stand corrected.

Elliott said...

Roy, you're right. I'm wrong. A little bit uncomfortable with some of what they have written since it seems a bit wrong-headed when it comes to political ideology. The public health stuff I've seen referenced from them was more mainstream and solid.

Mia said...

I am reading this post much after the fact because of the references to Himmelstein and Woodhandler.

I am amazed that people cannot even comment on self-described Marxists without being told they are red-bating. Some of the problems related to the health care debate are that the groups and people who advocate single-payer and socialized medicine are not accurately identified and described in the media. It is rare to see these folks identified by their political affiliations and leanings.

We cannot have an honest debate about the future of American health care if the discussion is hamstrung by political correctness.

Let's call a spade a spade and a Marxist a Marxist and move the discussion forward.

Thanks for this post. It was most informative.