Doctors No Longer Strong Republicans

JAMA Internal Medicine has some data which I would have predicted–doctors are less likely to support Republicans now than in the past. The data is based upon campaign contributions and therefore has no data regarding reasons for the change. This data would not include contributions under $200 and it is not known if those making smaller donations differ from the larger, reportable contributions.

The study found that since 1996 contributions to Republicans by physicians have decreased, dropping to under 50 percent leading up to the 2008 election. Many of the results suggest that doctors are contributing based upon factors comparable to the general population. This includes a significant gender gap with 57 percent of men and 31 percent of women contributing to Republicans over the entire study period. Leading up to the 2012 election, 52.3 percent of male physicians contributed to Republicans and 23.6 percent of female physicians contributed to Republicans.

I am apparently an exception to the trend that male physicians and physicians in solo or small practices are more likely to contribute to Republicans. Another trend mirrors the general population with those earning more being more likely to contribute to Republicans.

Overall the trend against support for Republicans is similar to the overall trend for more highly educated people to be less likely to support Republicans. The education in science might make many physicians more likely to reject Republicans in recent years as scientists have tended to oppose Republicans. Many people trained in science would have a difficult time supporting a party in which many believe in creationism, and most reject the view of 97 percent of climate scientists on global warming.

The study is unable to determine whether medically related issues have any bearing on the results. Democrats have been far more supportive of health care in recent years, but I also find that many of my colleagues get their news from Fox and have the same misconceptions about the Affordable Care Act and other issues as Republicans in general have. On the other hand, many physicians, along with many physician organizations, have been highly supportive of Obamacare after having seen the serious problems in health care delivery in this country. Republican policies would also be terrible for the future of Medicare, but I’m not sure how widespread this realization is among physicians.

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Increased Health Care Spending Just Might Be Buying Higher Quality Care


Jonathan Cohn has looked at what appears to be a recent increase in health care spending (national health expenditures in the above graph) after a period of decline. Most likely this is due to a variety of reasons, and I don’t find it surprising that a period of decreased spending would be followed by increased spending. This is partially a sign of an improving economy as people are less likely to put off spending on medical problems when they have more money available. The increase in people covered by insurance this year due to the Affordable Care Act should lead to a further increase in spending, but this spending is desirable

Cohn looked at a variety of possible causes but didn’t hit on the key point that increases in medical spending might not necessarily be a bad thing until late in the article:

It’s not always the case that spending more on health care is a bad thing. New or more treatments might alleviate suffering, reduce disability, or extend life—all of which have value. Providing insurance to more people, so that they are more secure financially, also has value. The reason to worry about high health care spending is that the extra money America spends doesn’t actually seem to buy America better health care. But, over the long run, the real goal of health care reforms should be a combination of restraining costs and improving quality.

Traditionally it has been true that we could not see benefits from increased spending compared to other countries, but there are factors in health care which could currently be causing increased spending compared to previous spending in the United States as well as increased quality. There has been a push for Medical Homes, increased payment for primary care services, and for increased attempts at payment of doctors based upon performance as opposed to fee for service alone. If doctors are given incentives to screen more for elevated cholesterol and do more to treat diabetic patients this would lead to increased spending, with this spending being beneficial.

Contrary to the argument that we were not seeing quality for our past spending, The New England Journal of Medicine reports this week that complications among diabetic patients have decreased between 1990 and 2010. The Annals of Internal Medicine also reports that between 1999 and 2010 the number diabetics has increased, with a decrease in the number who have the disease but are undiagnosed, and that treatment has improved. Both having more diabetic patients and providing treatment which results in better control is going to cost more money. It is too soon to have any data to see if there is a correlation between increased spending over the past year and quality of care, but I do wonder to what degree the trends I noted in the above paragraph are contributing to higher costs and how this might correspond with further improvements in the quality of care.

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Another Study Showing No Medical Benefits From Prayer

Periodically there have been reports in which someone actually bothered to compare medical outcomes with and without prayer. As expected, no benefit was found from situations in which someone was praying for someone else without their knowledge (to remove any psychological benefits). Irregular Times has reported on another study:

Does prayer really work wonders? Not according to epidemiologst Maria Inês da Rosa.

Da Rosa and her research team published results of a double-blind randomized trial in the Brazilian Journal of Science and Public Health last year. Half of the more than five hundred pregnant women in the trial had their health prayed for from a distance by a prayer team. The other half received no such prayers. When Da Rosa’s team measured the apgar scores, type of delivery and birth weight of the two groups, there was no difference in pregnancy outcomes.

A few years ago, intercessory prayer researchers were promising a golden age in which they would supposedly prove the effectiveness of their religion. That’s not happening. Careful science is establishing the opposite.

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The Success Of The Stimulus

Barack Obama’s economic stimulus was launched five years ago. Regardless of how successful it turned out to be, conservatives would attack it in order to try to avoid giving Obama credit for reversing the economic problems created by George Bush and Republican economic ideas. Michael Grunwald looked at the report from the Council of Economic Advisers on the success of the stimulus, finding that its report is consistent with other reports on economic improvement:

The main conclusion of the 70-page report — the White House gave me an advance draft — is that the Recovery Act increased U.S. GDP by roughly 2 to 2.5 percentage points from late 2009 through mid-2011, keeping us out of a double-dip recession. It added about 6 million “job years” (a full-time job for a full year) through the end of 2012. If you combine the Recovery Act with a series of follow-up measures, including unemployment-insurance extensions, small-business tax cuts and payroll tax cuts, the Administration’s fiscal stimulus produced a 2% to 3% increase in GDP in every quarter from late 2009 through 2012, and 9 million extra job years, according to the report.

The White House, of course, is not an objective source — Council of Economic Advisers chair Jason Furman, who oversaw the report, helped assemble the Recovery Act — but its estimates are in line with work by the nonpartisan Congressional Budget Office and a variety of private-sector analysts. Before Obama took office, it would have been a truism to assert that stimulus packages stimulate the economy: every 2008 presidential candidate proposed a stimulus, and Mitt Romney’s proposal was the most aggressive. In January 2009, House Republicans (including Paul Ryan) voted for a $715 billion stimulus bill that was almost as expansive as Obama’s. But even though the stimulus has been a partisan political football for the past five years, that truism still holds.

The report also estimates that the Recovery Act’s aid to victims of the Great Recession — in the form of expanded food stamps, earned-income tax credits, unemployment benefits and much more — directly prevented 5.3 million people from slipping below the poverty line. It also improved nearly 42,000 miles of roads, repaired over 2,700 bridges, funded 12,220 transit vehicles, improved more than 3,000 water projects and provided tax cuts to 160 million American workers.

My obsession with the stimulus has focused less on its short-term economic jolt than its long-term policy revolution: I wrote an article about it for TIME titled “How the Stimulus Is Changing America” and a book about it called The New New Deal. The Recovery Act jump-started clean energy in America, financing unprecedented investments in wind, solar, geothermal and other renewable sources of electricity. It advanced biofuels, electric vehicles and energy efficiency in every imaginable form. It helped fund the factories to build all that green stuff in the U.S., and research into the green technologies of tomorrow. It’s the reason U.S. wind production has increased 145% since 2008 and solar installations have increased more than 1,200%. The stimulus is also the reason the use of electronic medical records has more than doubled in doctors’ offices and almost quintupled in hospitals. It improved more than 110,000 miles of broadband infrastructure. It launched Race to the Top, the most ambitious national education reform in decades.

At a ceremony Thursday in the Mojave Desert, Energy Secretary Ernest Moniz dedicated the world’s largest solar plant, a billion-dollar stimulus project funded by the same loan program that financed the notorious Solyndra factory. It will be providing clean energy to 94,000 homes long after Solyndra has been forgotten. Unfortunately, the only long-term effect of the Recovery Act that’s gotten much attention has been its long-term effect on national deficits and debts. As the White House report makes clear, that effect is negligible. The overwhelming majority of the Recovery Act’s dollars have gone out the door; it’s no longer adding to the deficit. It did add about 0.1% to our 75-year debt projections, but allowing the economy to slip into a depression would have added a lot more debt.

Grunwald did warn of the political ramifications. As conservatives have convinced themselves that economic stimulus doesn’t work as a knee jerk reaction to anything proposed by Obama, politicians are likely to shy away from stimulus when needed in the future, following the European mistakes in promoting austerity. Such views in this country already led to the stimulus being significantly smaller than it should have been, especially in light of continuing problems with unemployment.


Steve Benen has more facts and tables on the benefits of the stimulus, such as the table above on the effect of the stimulus on GDP.

Think Progress cited several Republicans who attacked Obama on the stimulus and then took credit for its benefits.

Cross posted at The Moderate Voice

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Ignorance of Science In America

Earth From Moon

Last week I wrote about the debate between Bill Nye and Ken Ham on evolution versus creationism. Many scientists were justifiably annoyed that this was even a topic of  debate. We are contrasting evolution, based upon a tremendous body of actual evidence, with creationism, a belief lacking any evidence which is based purely upon religious dogma. I’ve noted in the past that a disturbing number of Americans do not accept evolution, which provides the foundation of modern biology. While far more Republicans deny evolution than Democrats and Independents, the problem is not limited to Republicans.

We see ignorance of science in many areas. While the tobacco industry has pretty much given up the battle against evidence that cigarette smoking is hazardous, we see essentially the same type of anti-scientific misinformation being spread by the petroleum industry regarding climate change denialism. The recent death of Philp Seymore Hoffman of a heroin overdose raised the issue that there are people who remain unaware of the science demonstrating that addiction is a disease, not just a bad choice.

Unfortunately ignorance of science is widespread in this country, often impacting views on public policy. The American Association for the Advancement of Science has released a survey demonstrating this ignorance:

Americans are enthusiastic about the promise of science but lack basic knowledge of it, with one in four unaware that the Earth revolves around the Sun, said a poll out Friday.

The survey included more than 2,200 people in the United States and was conducted by the National Science Foundation.

Nine questions about physical and biological science were on the quiz, and the average score — 6.5 correct — was barely a passing grade.

Just 74 percent of respondents knew that the Earth revolved around the Sun, according to the results released at the American Association for the Advancement of Science meeting in Chicago.

Fewer than half (48 percent) knew that human beings evolved from earlier species of animals.

The result of the survey, which is conducted every two years, will be included in a National Science Foundation report to President Barack Obama and US lawmakers.

One in three respondents said science should get more funding from the government.

Nearly 90 percent said the benefits of science outweigh any dangers, and about the same number expressed interest in learning about medical discoveries.

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The Bizarre World Of Health Care Charges

CMS released  data on what hospitals are charging today with many noticing, and questioning, vast differences in charges from one hospital to another. There are a few things you must know to make any sense out of this data.

Charges to Medicare have no bearing on what Medicare will pay. Medicare has a fee schedule for services, and will pay based upon this. Inpatient services are paid under a DRG (Diagnosis Related Group) system where Medicare pays a fixed amount regardless of what individual charges are present. This starts with the diagnosis, but the amount can be adjusted based upon factors such as severity and additional problems as obviously not every case admitted to the hospital for the same diagnosis is exactly the same. A hospital might charge $10 for a Tylenol tablet, but that doesn’t mean Medicare or an insurance company will pay it.

Some insurance companies pay the same way under a DRG system. I don’t know if this is true nation wide, but in Michigan Blue Cross also pays under a DRG system. Other insurers will pay based upon their fee schedule and not approve the full amount charged.  Hospital charges mean very little except for the uninsured. It is people without insurance who wind up being charged these ridiculously high rates. This means two things if you are without insurance and wind up in a hospital. First, it is often better to have a high deductible policy which never pays a cent than no insurance if the hospital has agreed to accept the plan’s rates. That way you will only have to pay what the insurance allows as opposed to the  hospital’s charge, which might be considerably higher. Of course make sure any insurance purchased this way really does have agreements with medical providers to accept their fees. Secondly, if you have a big bill and no insurance, keep in mind that the hospital would not receive the full amount if you had insurance. It is worth trying to negotiate and offering to pay a lower amount closer to what the hospital would expect to receive.

One consequence of this system of each insurance company approving different amounts for different services is that each hospital wants to be certain that they charge at least the maximum amount the best paying insurance company will pay. It is simpler to charge well above this amount to be certain of maximizing income.

This doesn’t necessarily mean they are evil and trying to rip off the system. The system makes this necessary for survival when each insurance company pays differently. While a simplification, imagine that someone is provided services A, B, and C when hospitalized. Some insurance companies might pay a fair amount for all three. Other insurance companies might pay extremely well for A, but poorly for B, and possibly not pay for C at all. Another insurance company might pay for B or C, but not for A. Health care providers must charge high amounts for all three, or risk not receiving enough to cover expenses. This means that the total charged for A, B, and C will be well beyond what they actually receive from any specific payer. Besides covering the actual costs to a particular patient, money must also be received for the tremendous overhead costs of hospitals and other health care facilities.

Yes, the system is screwed up, but it is often the system itself which is at fault, and comparing charges from different hospitals doesn’t provide all that meaningful information–except for the uninsured who will be charged more than Medicare or insurance companies will pay.

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Expanding Medicaid Coverage Is Beneficial (Ignore Those Conservative Bloggers Arguing Otherwise)

A study in The New England Journal of Medicine comparing people with and without Medicaid in Oregon provides an excellent example of how the right-wing blogs can take data and cherry pick the information which supports their views while ignoring the full set of information. The study does not provide evidence against expanding Medicaid through the Affordable Care Act, despite their spin. This is a topic which I wish I had more time to devote to tonight, but only have the time for some brief remarks.

The study shows that with some measures of medical care those receiving Medicaid coverage did better than similar adults who did not receive Medicaid coverage in Oregon’s lottery but there was not a large enough sample for the differences to be statistically significant. The most significant differences were reduced rates of depression and financial strain:

In particular, catastrophic expenditures, defined as out-of-pocket medical expenses exceeding 30% of income, were nearly eliminated.

Reducing financial strain is a rather significant benefit of having medical coverage. That’s also a key reason why so many people are concerned about receiving health care benefits from their employer and having Medicare coverage after they retire.

Showing improvements in measures of chronic diseases in a two year study, but not enough to be statistically significant yet, really comes as no surprise. It takes time to see major improvements in diabetes care, and the improvements shown in this study are a real start.

The results could be better. When I receive new diabetic patients who are poorly controlled I will see them every two weeks, and have them in for blood sugars in the time between these appointments. A new diabetic appointment will be well over an hour, and not uncommonly two hours. The glycated hemoglobin levels used in the study provide an average measure of blood sugar over the past 3 months. (It is a test of the effects of elevated blood sugars on red blood cells and provides an average based upon the life span of red blood cells). With intensive treatment of uncontrolled diabetics it still takes several months to see a statistically significant change.

I generally do see greater drops in glycosylated hemoglobin over the first year of treatment than this study is showing in two years. Of course this is not with Medicaid patients. No doctor could afford to do this with what Medicaid pays. The study shows that a poorly funded program provides some benefits. Giving the same people coverage at the level of private insurance, or at least Medicare, would probably result in even better outcomes. This study is not evidence that providing Medicaid doesn’t provide benefits, but it could be argued that to provide better results we should be putting even more money into health care benefits. I would also expect to see more impressive  improvement over a longer period of time.

I am surprised that they used HDL level as a measurement in the study as, while improving it will decrease the risk of heart disease, it is very difficult to change HDL levels regardless of medical intervention. Having Medicaid coverage would not be expected to affect this.

Two years is not long enough to meaningfully evaluate changes on chronic diseases. An evaluation of treatment for acute problems would be more meaningful over this time period. Kevin Drum’s impressions on this are correct:

The study suffers from the usual problem of measuring “outcomes,” and suffers especially because it measured only a very limited set of outcomes (primarily chronic conditions like blood pressure, cholesterol, and diabetes). This has long been one of my pet peeves. The problem is that there are lots of things that improve your quality of life but don’t show up as an improvement in either mortality rates or glycated hemoglobin levels. If I have an infection, for example, a course of antibiotics is a godsend. More than likely, though, the infection would have gone away eventually on its own. Does that mean the medication was useless? Of course not. Ditto for arthritis meds, a better pair of glasses, a new hip, a root canal, or fixing a broken ankle.

The truth is that if you take a narrow view of “outcomes,” it’s hard to find a significant effect from most of our healthcare efforts. Nonetheless, improved access to Medicaid produces plenty of improvement in acute problems; better use of preventive care; and far better financial outcomes. This is all worthwhile stuff even if controlling chronic conditions remains a challenge.


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Paul Ryan’s Plan To Destroy The Healthcare System

Paul Ryan might have to change his name to Paul W. Ryan after making this surprisingly honest comment on how his budget would affect health care:

This is something we will not give up on because we are not going to give up on destroying the healthcare system for the American people.

Ryan’s gaffe, or Freudian slip, is reminiscent of this classic from George W. Bush:

Our enemies are innovative and resourceful, and so are we. They never stop thinking about new ways to harm our country and our people, and neither do we.

Among the many other faults in the plan, Ryans budget slashes Medicare spending and turns it into a voucher system. Ezra Klein reviewed the plan, estimating that this would cause about 35 million to lose their health care coverage based upon estimates from the nonpartisan Kaiser Family Foundation.


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New York Soda Ban Invalidated

There was a major strike against the Nanny State today: A New York State Supreme Court judge struck down Michael Bloomberg’s regulation banning sugary drinks larger than 16 ounces.  He described the law as “arbitrary and capricious,” and questioned if it would be effective as intended to reduce obesity rates.

I spend a large part of the day treating patients with diabetes and understand what Bloomberg is trying to accomplish, but this is not a proper function of government. This is certainly not the end of this issue as Bloomberg has announced plans to appeal. Hopefully the appeal will fail, but perhaps the news surrounding this issue will cause some to reconsider their self-destructive habits. Ultimately we can try to educate, but the final decision rests with the individual.

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More Than You Are Probably Interested In Regarding The Sequester,The Affordable Care Act, and Physician Payment

I had been wondering why I have not received a notice from CMS that Medicare payments would be cut by two percent starting March 1 due to the sequester. It has become quite common to receive notices of possible cuts considering all the threatened cuts due to the sustainable growth formula which Congress repeatedly circumvents at the last minute. I found out today that the sequester doesn’t begin to affect Medicare payments until April 1. As Medicare routinely holds payments for two weeks, this actually means we will have six weeks for the sequester to be resolved before this becomes an issue.

Of course there are many other problems which will be caused by the sequester, some now and some down the road, and I don’t expect others to be overly concerned about small cuts in physician payment. Still for me this is a headache, not only because of a decrease in payments but because of the accounting headaches should this turn out to be temporary and the balance of the payments are sent at a later date.

We already have another situation causing us to have to receive partial payment and then the remainder at a later date. The Affordable Care Act calls for Medicaid payment for primary care services to be increased to Medicare levels for two years as of his January. Unfortunately what sounds like something simple has turned out to be bureaucratically quite difficult as the federal government has to approve the updated fee schedules from Medicaid programs from all fifty states. As of now, zero states have completed the approval process. This means that we are now being paid under the old fee schedules and will be paid the higher amounts retroactively to January at a later date. Those who understand how cumbersome medical billing is will recognize the nuisance this causes. Hopefully we won’t go through the same problems because of the sequester.

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