Thursday, August 8, 2013

We Can Learn About the Difficulties of Healthcare Reform from the Health Problems of Former Presidents

One of mantras of those who oppose healthcare reform is that it will deny people needed care. Programs that require measurement of healthcare quality or aim to discourage overuse of care are viewed by some as efforts to deny Americans their rightful access to healthcare. Consumers want "choice" to get the care they believe they need, and much of the healthcare system is well-configured with the financial incentive to meet that need.

This week, former President George W. Bush underwent a coronary stent procedure to open up a 70% blockage in one of his coronary arteries. The details of his symptoms are unclear but, as noted by an article in Forbes magazine [1], if President Bush was not having cardiac symptoms (e.g., chest pain), then there is no scientific evidence that the stenting procedure he underwent will prevent a future heart attack or prolong his life compared to just using optimal medical therapy (e.g., treatment of hypertension, hyperlipidemia, etc.) [2].

President Bush is not the only former President to have had possibly suboptimal healthcare for heart disease, which is still the top killer of Americans. President Bill Clinton also had heart problems, although he was acutely symptomatic and required urgent treatment. President Clinton was in suburban New York at the time and went to the nearest emergency department. This hospital had a referral arrangement with Columbia-Presbyterian Medical Center (CPMC) in New York City, where the former President was transferred. It turns out that CPMC, as great an academic medical center as it is, had poor performance on a number of quality measures in the New York State Cardiac Surgery Reporting System, a system whose data has been shown to be associated with beneficial clinical outcomes [3]. Even worse, the surgeon who operated on the former President had a worse-than-average rate of complications.

President Clinton did suffer a complication, and we cannot know for sure whether the complication was a result of the poorer quality care provided by his hospital or surgeon. But as noted in an article in Slate [4], this does raise questions as to the limits of consumer-driven healthcare. If two former Presidents, who presumably have more access to resources and information than anyone else on the planet, cannot make optimal healthcare decisions, can we expect the average consumer to do so? Of course, cardiac disease is one of those conditions for which we have more studies and more quality data than almost any other, and it gets worse from there.

It is unfortunate that a combination of politics and financial self-interest have created a climate of equating any attempt to rein in unnecessary healthcare as "denying" someone care. Focus groups of consumers show there is widespread skepticism, based on misunderstanding, of terms like "quality guidelines" and "evidence-based care" [5,6]. Efforts to have Medicare reimburse physicians for consultation about end-of-life care become "death panels" [7], the Politifact lie of the year for 2009. Efforts to be more appropriately evidence-based about the use of mammography in younger women were viewed as evidence of government malfeasance, when it reality more effective mammography would save the government money if they it led to improved treatment outcomes for breast cancer [8].

I certainly support patient engagement in healthcare decisions. I applaud the "Choosing Wisely" initiative of leading medical societies to highlight care that it is ineffective or outright dangerous [9]. But I remain, like many, frustrated that our political landscape and healthcare financing system impede a forthright discussion of the facts.


1. Husten, L (2013). Did George W. Bush Really Need A Stent? Forbes, August 6, 2013.
2. Stergiopoulos, K and Brown, DL (2012). Initial coronary stent implantation with medical therapy vs. medical therapy alone for stable coronary artery disease: meta-analysis of randomized controlled trials. Archives of Internal Medicine. 172: 312-319.
3. Jha, AK and Epstein, AM (2006). The predictive accuracy of the New York State coronary artery bypass surgery report-card system. Health Affairs. 25: 844-855.
4. Sanghavi, D (2009). Talk to the Invisible Hand - The promises and perils of treating patients more like consumers. Slate, September 28, 2009.
5. Carman, KL, Maurer, M, et al. (2010). Evidence that consumers are skeptical about evidence-based health care. Health Affairs. 29: 1400-1406.
6. Ross, M, Igus, T, et al. (2009). From our lips to whose ears? Consumer reaction to our current health care dialect. Permanente Journal. 13(1): 8-16.
7. Nyhan, B, Reifler, J, et al. (2013). The hazards of correcting myths about health care reform. Medical Care. 51: 127-132.
8. Quanstrum, KH and Hayward, RA (2010). Lessons from the mammography wars. New England Journal of Medicine. 363: 1076-1079.
9. Cassel, CK and Guest, JA (2012). Choosing wisely: helping physicians and patients make smart decisions about their care. Journal of the American Medical Association. 307: 1801-1802.

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