I have not written much about the seemingly endless health care reform debate in the US, because much of it has not been relevant to the issues we discuss on Health Care Renewal. Now that the current phase of the debate is done, and legislation has been passed, let me offer my opinions on the few aspects that do seem relevant to this blog.
The Sunshine Act
For Health Care Renewal readers, the most important part of the legislation is that containing the provisions of the Sunshine Act, championed by Senators Grassley and Kohl. (See this summary on Postscript, the Prescription Project blog.) The act requires that all drug, device, biologic, and medical supply manufacturers report essentially all payments to physicians or teaching hospitals to the goverment, and on the internet. It does not appear that the rules apply to other health care related non-profit organizations, e.g., medical schools, disease advocacy groups, health care related charities, medical societies, etc, or to payments made by for-profit health insurers, clinical research organizations, and some other corporations. Unfortunately, the provisions only take effect in 2013. However, despite these quibbles, this still may be one of the most important advances promoting disclosure of health care related conflicts of interest made in the 21st century.
Comparative Effectiveness Research
As best as I can tell at this point, the current legislation used the wording from the bill previously passed in the US Senate, which we discussed here and here, regarding comparative effectiveness research. Although its goal of setting up a not-for-profit comparative effectiveness organization seems laudable, the devil will be in the details. The Senate version gave considerable oversight of this organization to those with vested interests in selling particular products or services, threatening the impartiality of the organization and the research it would sponsor, and perhaps thus wholly defeating its ostensible purpose. Furthermore, the Senate bill included curious wording that seems to threaten the ability of those getting funding from the organization to express views that might disturb the organization's leadership, again threatening the integrity of their dissemination of its work, and perhaps violating the First Amendment of the US Constitution. Whether these provisions provide benefits that outweigh their harms is highly questionable.
Payments to Physicians
We have criticized how the process of setting payments to physicians by the US Medicare system has been captured by a secretive committee of the American Medical Association that is dominated by physicians who do procedures, the RBRVS Update Committee, or RUC. The results have been payments for primary care and other cognitive services that have failed to keep up with inflation, a major cause of the continuing decline of generalist/ primary care medicine in the US. (See most recent post here about this.) According to the summary provided by the American College of Physicians (here), the new legislation would enable review of payments made for specific services, and would reconsideration of the process used to set physician payments by an independent advisory group. However, the bill would not mandate any changes in payments, or in the processes used to set them, including the pivotal role of the RUC. So there is some chance that the legislation would lead to a more transparent, accountable, honest, and rational process for setting physician payments and hence eliminating perverse incentives, but no guarantee of such favorable changes.
The legislation seemingly will result in one major advance fostering disclosure of some conflicts of interest, and perhaps some progress in terms of reducing perverse incentives generated by Medicare's payments to physicians, and possibly reducing regulatory capture of this process. It likely will result in more comparative effectiveness research, but how badly it will be biased in favor of vested interests is unclear. As far as I can tell, the legislation will leave most of the other problems we discuss on Health Care Renewal untouched. We thus have one or two small steps for mankind, but no reason for complacency.
the news is not bad, but we are still a long way from meaningfully addressing concentration and abuse of power in health care. There will be no rest for the weary bloggers of Health Care Renewal.
Also, see comments here and here by Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma blog.
ADDENDUM (25 March, 2010) - Also see comments on the Sunshine Act by Alison Bass on the Alison Bass Blog.
"The idea that a university needs a discrete individual to be in charge of “integrity” or ethical conduct at all seems contrary to the very idea of a university as a place where learned people (teachers) instruct the to-be-learned in academic disciplines all of which have fairly well-understood ethical rules." - The University of North Carolina is creating a new position: "Chief Integrity Officer." Press Millen, a Raleigh trial lawyer, is not impressed.
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